The Medical Home Model: Patient Centered Care

1 | Group Health Solutions for Transforming Care

Michael Erikson, MSW, vice president, Primary Care Services

Robert Reid MD, PhD, MPH, associate medical director, Health Services Research & Knowledge Translation

Barbara Trehearne PhD, RN, vice president, Clinical Excellence, Quality, and Nursing Practice

Claire Trescott, MD, medical director, Primary Care Services

The Medical Home Model: Patient Centered Care


The Burning Platform of Primary Care

• Access to primary care difficult for many, particularly disadvantaged.

• Quality of remains mediocre with many gaps.

• Payment systems are antiquated. Many functions are unrewarded.

• Evidence-base has become unmanageable for individual physicians.

• Primary care is an unattractive career choice. Burnout common.


Medical Home Design Principles

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✔ The relationship between the clinician & patient is at our core. The entire delivery system will reorient to promote & sustain.

The primary care clinician will be a leader of the clinical team, responsible for coordination of services, and together with patients will create collaborative care plans.

Care will be proactive and comprehensive. Patients will be actively informed and encouraged to participate.

Access will be centered on patients needs, be available by various modes, and maximize the use of technology.

Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective experiences.


Informed,ActivatedPatient

ProductiveInteractions

Prepared,Proactive

Practice Team

DeliverySystemDesign

Decision

Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity Resources &

Policies

Health Care Organization

Improved Outcomes

The Chronic Care Model (CCM)

(Wagner EH et al, Managed Care Quarterly, 1999.7(3) 56-66)


Medical Home: Change Components

• Calls redirected to care teams• Secure e-mail • Phone encounters• Pre-visit chart review• Collaborative care plans• EHR best practice alerts• EHR prevention reminders• Defined team roles

Point-of-care changes• ED & urgent care visits• Hospital discharges• Quality deficiency reports• e-health risk assessment• Birthday reminder letters• Medication management• New patients

Patient-centered outreach

• Team huddles• Visual display systems• PDCA improvement cycles• Salary only MD compensation

Management & payment

PCMH Model


Group Health Medical Home Staffing Model

Increased Staffing (per 10,000 enrollees)

Physician (panels 2500 to 1800) 5.6 FTE 17%

PA/NP 1.5 FTE 70%

RN 1.2 FTE (no change)

LPN 2.0 FTE 65%

MA 5.6 FTE (no change)

Pharmacist 1.0 FTE 100%


Medical Home 1 & 2 Year Pilot Outcomes

Year 1 Year 2

Group Health Research Institute

QUALITY (HEDIS)

Year 1: Rate of rise, 2x that of control clinics

Year 2: Rate of rise continued to be 20-30% greater in 3 of 4 composites

PATIENT/STAFF SATISFACTION

Year 1: Patient satisfaction – 5% increase in patient activation/goal setting;

Practioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalization

Year 2: Scores continued to improve at Medical Home; controls were slightly worse

ED/UC UTILIZATION

Year 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but longer in-person visits

Year 2: Significant changes persisted

COST

Year 1: Cost is neutral

Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM)

Challenges Overcome


• All Work Processes are designed by staff who do the work

• Representatives from diverse clinics contribute to design

• Initial designs will be flawed, aim for 50% improvement

• All feedback from frontline staff will be recorded and used to improve processes

Essential Leadership Concepts


Key Elements: Management System

Links Business plan to front line workAlternative to “execution by wishful thinking”

Shows Performance Gaps Multiple Levels Driver

of Change

Reduce WasteImprove QualityPatients Point

of View

Accountability

Lean Management

System

Metrics and Visual Displays

Value Stream

Redesign


Our “Secret Sauce” for Spreading Standard Work

• MANAGEMENT BELONGS IN THE CLINICS

• Leaders must understand all standard work

• Leaders round on all standard work daily or weekly

• Processes and outcomes are visible in the clinic

• Where we struggled with implementation it was ALWAYS because of leadership problems

• Work in the clinics is linked to visible data at all levels of management


Current Innovation: Frontline Improvement Initiative

• Moving from Adaptive Leadership to an Adaptive Workforce

• Designing for a world of continuous change

• Using Lean principles to do structured changes in everyday processes


Building Teams

• Probably our most difficult leadership challenge

• Co-location does not guarantee teamwork

• Physician’s not necessarily trained to work in teams

• Huddles essential and continue to offer opportunities

• Nursing changes challenging

• Visible Patient Care Boards are effective


Nursing Boards


Medical Home: Role of Nursing

• Outpatients require higher level of care

• Increased complexity of care requires higher skill for coordination and chronic disease management

• Skilled RNs can effectively manage chronic illness in partnership with a well developed interdisciplinary team

• Team RNs and Complex Case Managers focus on self management support & increasing motivation to improve adherence to care/medications

• Team based RNs can assess broad spectrum of needs, partner with patient and PCP, develop plan of action, coordinate resources


Nursing Challenges

• Capacity for managing both acute and chronic populations

• Need to rethink skill development; what do nurses need to know

• Role changes from ‘tradition’ outpatient to patient centered, focus on self management, coordination of care

Transition to the Future Medical Home Model


Rethinking Medical Centers


Transformational Thinking

See what’s not there

Reframe

Move

Think about nature

Journalistic Six

Word Association

Change your lens


Next Evolution of Our Clinical Transformation

Patient-Centered Medical Home

CSS Honors

2010 Achievements

• PDP

• Virtual Visits

• Call Management


Care & Facility Redesign Opportunities


What’s Next for Medical Home?

Integrated Care & Facility Design – Using 3P

As an extension to Group Health's medical home practice redesign, we are looking to the next stage to:

• Redesign how the staff optimally interacted with each other and their patients

• Redesign the staffing. Redesign the physical work environment to further optimize our clinical work and patient’s experience

The brick and mortar solutions will focus on:• Standardization of rooms, materials, furniture, equipment• Modular walls and furniture• Sustainability with a focus on mechanical systems• Evidence based design solutions• Integrated Project Delivery Agreements


Integrated Care & Facility Design – Using 3P

The brick and mortar solutions will focus on:• Increasingly more care is virtual

PhoneE-visitsConsultations between medical-surgical specialties

• Co-design all processes that patients use or touch within a visitCheck-in – business functionClinicalAncillary

• Design those processes around the patient: be patient centeredExample-Bring services to patients-Reduce/eliminate waiting-Can waiting rooms become unnecessary?

• Consider & design all material supply chains to reduce inventory and turn rates

• Design in flexibility, quality while reducing overall facilities costs• Partner with architects, builders differently

What’s Next for Medical Home?

The Medical Home Model: Patient Centered Care

Health & Medicine

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