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![Page 1: Whats Needed In Primary Care? J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community.](https://reader035.fdocuments.in/reader035/viewer/2022070305/5514d72c55034640138b6397/html5/thumbnails/1.jpg)
What’s Needed In Primary Care?What’s Needed In Primary Care?
J. Lloyd Michener, MD
Professor and Chair
Department of Community and Family Medicine
Director, Duke Center for Community Research
Bridging the Chasm
Health Level Seven
April 20, 2009
Washington, DC
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Twenty years of experience trying to improve Twenty years of experience trying to improve outcomes and lower costs for diverse communities in outcomes and lower costs for diverse communities in
North CarolinaNorth Carolina
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Community Care PartnersCommunity Care Partners 42,000 Medicaid patients, Durham (NPCCN), Vance, Granville, Warren, Person, and Franklin Counties in 34 primary care practices Primarily women and children, largely African-American, growing Latino population Teams of community health workers, DSS social workers, nurses work with patients at home Offer patient education, patient support, system navigation, and self-management skill training Electronically linked between practices, hospitals, DSS, Health Depts., and the teams
Clinical Outcomes (State):Clinical Outcomes (State):• 34% lower hospital admission rates34% lower hospital admission rates• 8% lower ED rate8% lower ED rate
Financial Outcomes (State):Financial Outcomes (State):• 24% lower average episode cost for 24% lower average episode cost for children ($687 v $853)children ($687 v $853)• $3.5 million/yr for asthma management$3.5 million/yr for asthma management• $2.1 million/yr for diabetes management$2.1 million/yr for diabetes management• $60 million in SFY03$60 million in SFY03• $124 million in SFY04$124 million in SFY04TotalTotal::
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Walltown and Lyon Park ClinicsWalltown and Lyon Park Clinics
Duke-Durham Neighborhood Partnership:Duke-Durham Neighborhood Partnership:• Neighborhoods ask for access to careNeighborhoods ask for access to care• Population: African-American, new Latino population, Population: African-American, new Latino population,
low-income, transient, uninsuredlow-income, transient, uninsured• Health characteristics: high ED use; inconsistent Health characteristics: high ED use; inconsistent
primary care, high risk health behaviors; substance primary care, high risk health behaviors; substance abuse; depression/anxietyabuse; depression/anxiety
• 70% of visits are return visits (continuity)70% of visits are return visits (continuity)• 37% of patients surveyed would have gone to ED37% of patients surveyed would have gone to ED• High patient satisfaction – 4.7/5.0High patient satisfaction – 4.7/5.0
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Since 2000, serving 350 patients, average age 70 Since 2000, serving 350 patients, average age 70
who have multiple chronic conditionswho have multiple chronic conditions
44% have mental illness44% have mental illness All are home boundAll are home bound 84% are African-American; many with low to no 84% are African-American; many with low to no
family supportfamily support Low literacy; illiterate Low literacy; illiterate
Just for UsJust for Us
Community Partners:Community Partners:City of Durham, Housing AuthorityCity of Durham, Housing AuthorityLincoln Community Health CenterLincoln Community Health CenterDurham Council on SeniorsDurham Council on SeniorsArea Mental Health AgencyArea Mental Health AgencyDurham County Health DepartmentDurham County Health DepartmentDurham County Department of Social ServicesDurham County Department of Social Services
Practice Partners:Practice Partners:Duke CFM, SON, DUH, DRH, Center for Aging, Duke CFM, SON, DUH, DRH, Center for Aging, Department of PsychiatryDepartment of Psychiatry
All patients with hypertension 79% ≤ 140/90All patients with hypertension 79% ≤ 140/90Diabetics with hypertensionDiabetics with hypertension 84% ≤ 140/90 84% ≤ 140/90
OutcomesOutcomesAmbulance costsAmbulance costs ↓ 49%↓ 49%ER costsER costs ↓ 41%↓ 41%Inpatient costsInpatient costs ↓ 68%↓ 68%Prescription costsPrescription costs ↑ 25%↑ 25%Home health costsHome health costs ↑ 52%↑ 52%
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Community RedesignCommunity Redesign
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Durham Health Innovations (DHI): Durham Health Innovations (DHI): City of Medicine/Community of Health City of Medicine/Community of Health
Key points:Key points: Grants are for planningGrants are for planning Relationships and teamworkRelationships and teamwork Improve the health of our communityImprove the health of our community Work with the DCCR Team and additional resourcesWork with the DCCR Team and additional resources This is a collaborative process – we will work together, This is a collaborative process – we will work together,
learn together, and succeed togetherlearn together, and succeed together
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Proposals…Proposals…
1.1. Adolescent HealthAdolescent Health
2.2. Asthma / COPDAsthma / COPD
3.3. CancerCancer
4.4. Cardiovascular Disease/CKDCardiovascular Disease/CKD
5.5. DiabetesDiabetes
6.6. HIV/AIDS, STDs, HepatitisHIV/AIDS, STDs, Hepatitis
7.7. Maternal HealthMaternal Health
8.8. Obesity Obesity
9.9. Obesity & WellnessObesity & Wellness
10.10. Pain ManagementPain Management
11.11. Substance AbuseSubstance Abuse
12.12. Seniors HealthSeniors Health
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Medical Home Version 1Focus: Improved outcomes for patients seen in officeCare Location: Offices and hospitalsIT: MinimalProvider: Physicians and Office team
IT
Office
Anywhere
Office Team
Community Team
Patients
Physicians
Hospital
Example: Duke Family Medicine, Duke Primary Care, General Peds, Duke Outpatient Clinic
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Medical Home Version 2 – Our Current State: What do We Medical Home Version 2 – Our Current State: What do We Have and What do We Still Need to Do?Have and What do We Still Need to Do?
IT
Office
Anywhere
Office Team
Community Team
Patients
Physicians
Hospital
Communication Tools • Telephone • Email • Text messages• Kiosks• Patient Portal
Care Management Tools • Risk assessment• Data surveillance • Care plans• CMA/CHW• Group visits
Community Partners/Sites• Neighborhood care • Patient surveillance • Point of care testing• Neighborhood nurses• Medication access
Focus: Improved outcomes for patients seen across the spectrum of careFocus: Improved outcomes for patients seen across the spectrum of careCare Location: Offices and hospitalsCare Location: Offices and hospitalsIT: Somewhat integratedIT: Somewhat integratedProvider: Physicians, Office team, and Community teamProvider: Physicians, Office team, and Community team
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Medical Home Version 3 – Connected CareMedical Home Version 3 – Connected Care
IT
Office
Anywhere
Office Team
Community Team
Patients
Physicians
Hospital
Focus: Improved outcomes for allFocus: Improved outcomes for allCare Location: AnywhereCare Location: AnywhereIT: Highly integratedIT: Highly integratedProvider: NetworkProvider: Network
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IT for Primary CareIT for Primary CareWhat’s Needed?What’s Needed?
1.1. Shared patient data repository across Shared patient data repository across community partnerscommunity partnersPrototype solution – COACH/NPCCNPrototype solution – COACH/NPCCN
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Network PartnersNetwork Partners
2 Care Management Teams2 Care Management Teams 34 Primary Care Clinics (FM, IM, Peds, Ob-Gyn, 34 Primary Care Clinics (FM, IM, Peds, Ob-Gyn,
FQHC)FQHC) 3 Urgent Care Facilities 3 Urgent Care Facilities 5 Hospitals and Emergency Depts.5 Hospitals and Emergency Depts. 8 Government Agencies (HD, DSS)8 Government Agencies (HD, DSS)
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HL7 DSS – Architectural OverviewHL7 DSS – Architectural Overview
Decision Support Service
Decision Support Service
Knowledge Modules
Knowledge Modules
Institution A Institution A
Client Decision Support Apps
Client Decision Support Apps
Patient Data Sources
Patient Data Sources
Queries for required ptdata
Queries for required ptdata
Institution B Institution B
Client Decision Support Apps
Client Decision Support Apps
Patient Data Sources
Patient Data Sources
Queries for required ptdata
Queries for required ptdata
Conclusions about patientConclusions about patient
Patient data, knowledge modules to use
Patient data, knowledge modules to use
©2009 Kensaku Kawamoto©2009 Kensaku Kawamoto
Trigger
HL7 DSS StandardHL7 DSS Standard
Trigger
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COACH HIE ContextCOACH HIE Context
Enables Population Health Management model of care Enables Population Health Management model of care Supports care management activities (documentation, Supports care management activities (documentation,
communication, referrals, care plans, etc.)communication, referrals, care plans, etc.) Receives and displays external billing/claims/clinical data from 5 Receives and displays external billing/claims/clinical data from 5
hospitals, 8 clinics and NC State Medicaidhospitals, 8 clinics and NC State Medicaid 6 Counties => 40,000 Medicaid Beneficiaries6 Counties => 40,000 Medicaid Beneficiaries Centralized data repositoryCentralized data repository
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2.2. Systems to support population health Systems to support population health managementmanagementPrototype solution – COACH population health Prototype solution – COACH population health
management system for NPCCNmanagement system for NPCCN
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CDS RepositoryCDS Repository
HL7HL7Decision Support Decision Support
ServiceService
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COACH Sample ScreenCOACH Sample Screen
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Sample Provider NoticeSample Provider Notice
©2009 David F. Lobach©2009 David F. Lobach
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3.3. Tools to support efficient point-of-care Tools to support efficient point-of-care decision making regarding health decision making regarding health maintenance maintenance Prototype solution – eBrowser disease Prototype solution – eBrowser disease
management dashboard management dashboard
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Duke eBrowser – Disease Management Module
© 2007 David F. Lobach
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4.4. Ability to identify clinic and provider level Ability to identify clinic and provider level performance on care quality metricsperformance on care quality metricsPrototype solution – DHTS care quality reports Prototype solution – DHTS care quality reports
powered by CDR, DSR, and SEBASTIANpowered by CDR, DSR, and SEBASTIAN
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Duke Health Disease Management System – Reporting for Diabetes
© 2009 David F. Lobach
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Outstanding ChallengesOutstanding Challenges
Data standards (e.g., HL7 version 3 standards) are too Data standards (e.g., HL7 version 3 standards) are too complex and costly to routinely implementcomplex and costly to routinely implement
Lack of incentives to share dataLack of incentives to share data Training on data collection and data entryTraining on data collection and data entry