Transforming Primary Care: Creating and Sustaining Change · 2014-11-10 · Clinical Quality...

Transforming Primary Care:Creating and Sustaining Change

Judith Steinberg, MD, MPHRussell Phillips, MD

Pam Cormier MSN, RNMimi Jolliffe, NP

Importance of transforming care by disrupting practices Changes in policy and payment Sustaining change: PCMH initiatives and lessons learned A story of transformation: Brookside CHC

Agenda

The Importance of Primary Care

Health systems and regions with a strong foundation of primary care have: Better population health outcomes Better quality of care More preventive care Lower costs More equitable care and mitigation of health disparities

Source: Starfield et al, Milbank Q 2005; 83:457‐502.

Accountable Care Organizations

Provider‐led organizations with a strong base of primary care that are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients.

Payments linked to quality improvements that also reduce overall costs.

Reliable and progressively more sophisticated performance measurement

McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. Health Aff.2010;29(5):982–90.

PCMHs are the foundation of Accountable Care Organizations

PCMH Joint Principles: Integrating Behavioral Health

PCMH PrinciplesPersonal PCP

Whole person orientationCare coordinatedQuality and safetyEnhanced access

Appropriate payment

BH IntegrationHome of the teamRequires BH service as part of careShared problem & med listsRequires BH on teamIncludes BH for patient, fam & providerFunding pooled & flexible

Ann Fam Med 2014; 183‐185; Joint Principles from AAFP, ABFM, STFM

NCQA PCMH 2014 Content and Scoring

Medical Homes Across the US 44 states have Medicaid/CHIP PCMH initiatives

• 35 states include payment reform 18 states have multi‐payer initiatives

Patient Centered Primary Care Collaborative

8MA Health Care Reform Legislation

Health Homes

MA PCMH Initiatives

Primary Care Payment Reform

Safety Net Medical Home

CHIPRA Medical Home

HMS Academic Innovations Collaborative

Massachusetts Patient‐Centered Medical Home Initiative

Multi‐payer, statewide initiative Sponsored by MA Health & Human Services, legislatively mandated 44 participating practices 3‐year demonstration; Start: March 29, 2011

Includes payment reform

Vision: All MA primary care practices will be PCMHs by 2015

9

Recognition Level Number/Percent

Level One 4/9%

Level Two 12/27%

Level Three 37/61%

97% of practices achieved NCQA RecognitionMA PCMHI NCQA Dashboard

Access PCMH Team Quality HIT Coord Care

Mgt Total

Baseline 37 67 77 74 78 64 60 68Mid‐Point 48 75 84 80 79 71 68 72Final 54 84 89 84 84 77 80 78

0102030405060708090100

Practice Self AssessmentTransformation: Change Over Time

Assessment tool: Medical Home Implementation Quotient MHIQ®

Clinical Quality Measures: Significant Improvement in Change over Time

25.2 23.8

37.1

82.4

46.5

16.7 17.3

11.5

18.6

46.4

22.3

36.1

48.7

32.0

47.6

90.5

51.3

25.321.4 19.3

62.7 63.1 61.264.7

0

10

20

30

40

50

60

70

80

90

100

Screened forDepression

Self‐Management

Goal

Adult WeightScreening &Follow‐Up

Tobacco UseAssessment

TobaccoCessation

Intervention

HypertensionSelf‐

ManagementGoal

DepressionPHQ‐9 Score

DepressionSelf‐

ManagementGoal

Patients WithAction Plan

ImmunizationStatusMultipleVaccines 1

ImmunizationStatusMultipleVaccines 2

Care Plans forHighest RiskPatients

Percen

t

Baseline Time 11

11/22 measures showed statistically significant improvement

Adult Diabetes Adult Prevention Other Adult Measures Pediatric Asthma

Childhood Prevention

Care Management

65 Primary Care Practice Sites Supported by 5 Regional Coordinating Centers

Five Regional Coordinating Centers (orange) were selected from 42 applicants (blue) to participate

1. Colorado Community Health Network

2. Idaho Primary Care Association

3. Massachusetts League for Community Health Centers and Massachusetts Executive Office of HHS

4. Oregon Primary Care Association & CareOregon

5. Pittsburgh Regional Health Initiative

Safety Net Medical Home Initiative

Courtesy Jonathan Sugarman, CEO Qualis Health

The Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient‐Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241‐259.

SNMH Framework


1

2

3

4

5

6

7

8

9

10

11

12PC

MH

-A S

core

Change Concept

Average Change Concept Scores Across All Partner Sites*Mar 2010 - Mar 2013

Numbers in boxes are the increase in Change Concept from Mar 2010 to Mar 2013

Mar-10 Sep-10 Mar-11 Sep-11

+2.1 +2.1 +3.1 +2.2 +2.3 +2.3 +1.7 +1.7 +2.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%M

ay-1

0Ju

n-10

Jul-1

0A

ug-1

0S

ep-1

0O

ct-1

0N

ov-1

0D

ec-1

0Ja

n-11

Feb-

11M

ar-1

1A

pr-1

1M

ay-1

1Ju

n-11

Jul-1

1A

ug-1

1S

ep-1

1O

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1N

ov-1

1D

ec-1

1Ja

n-12

Feb-

12M

ar-1

2A

pr-1

2M

ay-1

2Ju

n-12

Jul-1

2A

ug-1

2S

ep-1

2O

ct-1

2N

ov-1

2D

ec-1

2Ja

n-13

Feb-

13M

ar-1

3A

pr-1

3M

ay-1

3Ju

n-13

Jul-1

3A

ug-1

3S

ep-1

3

Perc

ent R

ecog

nitio

n A

chie

ved

(Tot

al =

64

Site

s)

Date

SNMHI PCMH RecognitionState or NCQA PCMH Recognition NCQA PCMH Recognition

Goal line

81% of Sites Achieved PCMH Recognition


Element of technical assistance% of sites rating“helpful” or “very helpful”

National Summit attended by all practices 92.7%

Field trips or site visits 91.2%

Regional meetings 89.4%

Implementation guides 87.5%

Elements of Technical Assistance Most HighlyValued by SNMHI Practices


Created and implemented a durable framework to guide effective transformation within and beyond the safety net

Facilitated significant changes in health care delivery and practice culture among participating practices

Developed a cohort of safety net sites to serve as exemplars and leaders in medical home transformation

Developed a comprehensive library of public domain resources and tools created by and for primary care practices

Enduring Contributions


Primary Care Payment Reform

MassHealth’s flagship alternative payment program that will enable MassHealth to move from fee‐for‐service reimbursement towards alternative payment models.

Goals:

• To improve access, patient experience, quality, and efficiency through care management and coordination and integration of behavioral health

• Increase accountability for the total cost of care

28 participating practice organizations, 47 sites

Comprehensive Primary Care Payment (CPCP)

Risk‐adjusted capitated payment for primary care services

Options for including outpatient behavioral health services

Quality Improvement Payment

Annual incentive for quality performance, based on primary care performance

Shared savings payment

Primary care providers share in savings on non primary care spend, including hospital and specialist services

A

B

C

Massachusetts Primary Care Payment Reform

Building 3 Behavioral Health Tiers into the Comprehensive Primary Care Payment

Tier 1• Integrated care management• No fee‐for‐service behavioral

health billable services

Tier 2 • BH services by Master’s or

Doctoral level professional• Fee‐for‐service billable

outpatient

Tier 3 • Fee‐for‐service billable

outpatient BH services provided by prescribing clinicians and psychotherapists

• Medication management• Psychiatric assessments• Psychotherapy

UMass Learning Collaboratives: MA PCMHI and PCPR Transformation Resources 10 learning sessions, 6 on‐line courses, many webinars Clinical Care Management Curriculum Medical Home Facilitator expertise Shared savings methodology MA PCMHI website: practice tools, webinars, learning

sessions, online courses, links, communications Patient/family engagement practice toolkit Behavioral health integration elements, assessment and

toolkit Physician Leadership Institute

Academic Innovations Collaborative (AIC)

Launched in July 2012, the AIC is catalyzing transformation at 20 primary care teaching practices through innovation in: Team‐based primary care, Management and prevention of chronic illnesses, Management of patients with multiple illnesses, Patient partnership and behavior change.

Academic Innovations Collaborative (AIC) 19 AMC‐affiliated primary care practices 6 hospital‐based 13 Community health centers and private practices

11 Residency programs 7 Internal medicine, 1 family medicine, 1 med‐peds,

2 pediatrics

Components of AIC Intervention Learning sessions with curriculum Monthly meetings of day‐to‐day leaders Monthly meetings of project managers Monthly transformation updates (metrics) Leadership Academy Practice coaching

The Work of the AIC

Aim Statement #1:•Assign Panels•Team‐based Care Teams•Outreach to Patientsby July 2013

Aim Statement #2:•Balance Panels•Team Huddles•Self‐Management Goalsby January 2014

Aim Statement #3:•Balance Panels•Pre‐ and Post‐visit•Planned Care Visitsby July 2014

AIC Data: PCMH Score

1

2

3

4

5

6

7

8

9

10

11

12

6.4 6.3

7.9 7.8

6.57.0

8.0

8.7

5.9

7.17.5

8.5

7.0 7.0

8.3

9.0

6.0

6.6

7.2

7.8

6.3

7.37.8

8.3

7.6

8.3

8.9 9.0

7.2

8.58.3

9.2

6.5

7.58.1 8.3

Enga

ged

Lead

ersh

ip

Qua

lity

Impr

ovem

ent

Stra

tegy

Empa

nelm

ent

Con

tinuo

usTe

am-b

ased

Hea

ling

Rel

atio

nshi

ps

Patie

nt-c

ente

red

Inte

ract

ions

Org

aniz

edEv

iden

ce-b

ased

Car

e

Enha

nced

Acc

ess

Car

eC

oord

inat

ion

Ove

rall

Scor

e

PCM

H-A

Sco

re

AIC: Jul-12 AIC: Jan-13 AIC: Jul-13 AIC: Jan-14

Median PCMH‐A Scores by Change ConceptAIC Practices Jul 2012 – Jan 2014

Key Lessons Learned

Primary care has capacity to lead change in AMCs through improved systems of care

Success is built on a foundation of engaged leadership, process improvement, and teaming

The Qualis change concepts provide a useful roadmap that can be contextually adapted

Measurement is KEY Building teams is both a process AND an outcome Partnering with patients and trainees is critical

MA PCMHI Qualitative Evaluation: 5 Factors Contributing to Transformation

Sequence of core competency adoption Strong leadership and staff buy‐in Focus on staff capacity and resources Electronic Medical Record (EMR) proficiency Active use of available technical assistance and peer

learning

Sequencing: Build the Home from the Foundation Up

Leadership EngagementLeadership

EngagementData-Driven Quality

ImprovementData-Driven Quality

ImprovementPatient Involvement in

TransformationPatient Involvement in

Transformation

Multidisciplinary Care Team


Evidenced-based, Pro-active care delivery


Patient-centeredness


Care Coordination

Care Coordination

Clinic System Integration


Clinical Care ManagementClinical Care Management

Implement Care Integration in each PCMH Component

Leadership EngagementLeadership

EngagementData-Driven Quality

ImprovementData-Driven Quality

ImprovementPatient Involvement in

TransformationPatient Involvement in

Transformation







Care Coordination

Care Coordination



Clinical Care ManagementClinical Care Management

Tips for Getting Started on the PCMH Journey Conduct a practice assessment of the current state Develop a transformation plan Identify an interdisciplinary improvement team; include

patients Identify the functions needed in the care model Assign care team members roles and responsibilities Invest in team functioning Assign patients to teams Invest in QI infrastructure Let the data guide the way Understand and leverage new payment models

A Story of Transformation: Brookside CHC

Brookside Community Health Center

Located in Jamaica Plain Established in 1970 Provides Primary Care, Dental Care, Behavioral Health

Services and WIC/Nutrition to people of all ages residing in Boston Neighborhoods

68,000+ visits annually to the health center 11,000+ patients Licensed by Brigham and Women’s Hospital

Medical Department

6 Adult providers 4 Pediatricians 4 Family Nurse Practitioners 1 OB/GYN Surgeon 3 Nurse Midwives 1 Cardiologist 2 Pulmonologists (Adult and Pedi)

Transformation Projects: Empanelment

Assigned every patient to a PCP 4 Cut method to establish PCPs for patients System for patients to change PCP Coordinated Distribution of new patients

Population Health Management Diabetes HTN Colorectal Screening

Continuous & Team Based Healing Relationships: Sample Team Structure

Continuous & Team Based Healing Relationships

5 Care Teams 3 Adult, Pedi, and OB/GYN

MA and LPN role redefinedRN assigned to each teamAligned schedules of providers and support staffHuddle/team meeting

Continuous & Team Based Healing Relationships

Transformation Project: Quality Improvement

Clinical Messaging Overhaul Developed standard subject lines Allowed recipient to quickly prioritize

Created templates with scripts Ensured all information was gathered while caller

was on the phone Standard expectations for patients

Defined which role to receive message Prevented rework and clutter

Transformation Project: Quality Improvement

0

30

60

90

120

150

180

Sent Clinical Messages by Hour

April 21‐25

April 28‐May 2

May 5‐9

May 12‐16

Transformation Projects: Enhanced Access

LPN Clinics 1 session per week Providers select appropriate patients 30 minute appointments Med teaching Injections HTN teaching

Transformation Projects: Care Coordination

ED Follow‐up phone calls

Questions and Discussion

Contact

Center for Primary Care617‐432‐2222

https://primarycare.hms.harvard.edu

Extra slides

US spends the most and is ranked the lowest

Pro‐Active MultidisciplinaryTeam‐based Care

47

Old Model

48

Old Model

49

Pro‐Active Multidisciplinary Team‐based Care

50


51

Transforming Education

Transforming Care Systems

Creating New Approaches to Primary Care and Health

A New Vision for Primary Care at HMS

Our Impact Improving the experience of care for

patients and their families/caregivers; Improving the experience of the primary

care workforce; Improving the experience of educators and

trainees; Offering solutions that improve value in

health care by redesigning existing care systems to optimize the quality, safety, and reliability of care, while containing costs; and

Creating new approaches to primary care and health, outside of existing systems.

Practice Change

Educational Change

Transforming Primary Care: Creating and Sustaining Change · 2014-11-10 · Clinical Quality...

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