Transforming CHCs into Practices of the Future

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Transforming CHCs into Practices of the Future

• Bery Engebretsen, MD
• Clinical Consultant IANEPCA
• Medical Director, Primary Health Care, Inc
• Kansas City, MO
• 12/11/2007

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I cant do that in a 15 minute
appointment.(Treat chief complaint and provide
immunizations, routine screening, preventive
care, address psycho/social issues, manage meds,
gather data for registry activities, educate,
coordinate with other care,..)
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The brief visit model is an acute care model. It
is not designed for the complex world of what is
expected of todays ambulatory care. And it is
not working.How can we make our system of care
work?
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Prevention an example of the possibilities

• Partnership for Prevention
• Raising five preventive practices from current
  rate to 90 would save 100,000 lives a year
• ASA Smoking colorectal screening influenza
  breast cancer screening
• All high impact, low cost interventions
• But, how to accomplish?

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Prevention

• Partnership for Prevention why we do poorly
• Lack systems to track, contact, remind, follow-up
• Lack of medical home
• Public lack of awareness
• Payment encourages acute and specialty care
• High out of pocket for prevention

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Outline

• I. Medical Home principles
• A. Definition, background
• B. High tech concepts
• C. High touch concepts
• II. Changing care with Toyota lean redesign
  principles
• III. Paying for it

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A. Definition Medical Home

• Family practice in the 60s 70s
• Primary care in the 80s
• Gatekeepers in the 90s
• Will the medical home succeed where the others
  failed??

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A. The Medical Home

• Simple definition A health care setting that
  provides patients with timely, well-organized
  care and enhanced access to providers.

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Commonwealth study of U.S. medical home patients
reported that they

• Had a regular provider or source of care
• Had no problem contacting provider by phone
• Could get care or advice on the weekends
• Reported office visits are organized and on
  schedule

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Commonwealth patients with a medical home

• Were more often insured
• Had no racial disparities regardless of insurance
  status, if they had a medical home
• Were more likely to have preventive screening

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Commonwealth medical home study

• Looked at process of care and not outcomes
• Private practice patients were more apt to report
  a medical home (32) than CHC patients (21)

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A second international study by Commonwealth

• Australia, Canada, Germany, Netherlands, New
  Zealand, United Kingdom, U.S
• Those with medical homes faired better in all
  countries
• The U.S. stood out for cost-related access
  barriers and less efficient care

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Commonwealth international study

• Errors were high with multiple doctors or
  multiple problems
• For models of access to care, we might look to
  any of the seven countries except the U.S and
  Canada

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A. Medical Home complex definition

• Access is easy, timely and by multiple means
• Focuses on populations of patients as well as
  individual patients
• Patient centered care and self management
  actively encouraged
• Uses evidence based care
• Uses data extensively, on the population,
  individual, and practice, to monitor and intervene

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NCQA PCMH-PPC Proposed Content and Scoring (Draft
7-07)
Must Pass Italicized new elements
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Sections (Points)

• PPC 1 Access Communication (9)
• PPC 2 Patient Tracking Registry Functions
  (21)
• PPC 3 Care Management (20)
• PPC 4 Patient Self-Management Support (6)
• PPC 5 Electronic Prescribing (8)
• PPC 6 Test Tracking (13)
• PPC 7 Referral Tracking (4)
• PPC 8 Performance Reporting Improvement (15)
• PPC 9 Advanced Electronic Communication (4)
• TOTAL POINTS 100

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Must Pass Elements (Points) Pass 50 of
Element

• 1A Access Communication Processes (4)
• 1B Access Communication Results (5)
• 2D Organizing Clinical Data (6)
• 2E Identifying Important Conditions (4)
• 3A Guidelines for Important Conditions (3)
• 4B Self-Management Support (4)
• 6A Test Tracking and Follow-Up (7)
• 7A Referral Tracking (4)
• 8A Measures of Performance (by MD Practice)
  (3)
• 8C Reporting to Physicians (3)
• TOTAL POINTS 43
• POINTS NEEDED TO PASS 21.5

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Achieving PC-MH Recognition

• Basic recognition would be achieved at a point
  total of 25
• Must Pass elements account for 21.5 of the 25
  points needed if all are passed at the 50 level
• Practices can do better than 50 on must pass
  elements OR accrue points on other elements
• For level 1 recognition, practice needs to
  pass 5 of the 10 Must pass elements AND
  achieve a minimum of 25 points in total (points
  can be accrued from elements not part of the
  must pass ten
• Higher recognition would be achieved at 50 and 75
  points

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Achieving Must Pass

• Access/Communication Processes (1A) need 4-6 out
  of 11 elements
• Example of 4 elements
• Determining through triage how soon a patient
  needs to be seen
• Scheduling same day appts based on triage
• Providing urgent phone response within a
  specified time, 24/7
• Scheduling patient with a personal clinician for
  continuity of care

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Achieving Must Pass

• Access Communication Results (1B)
• Visits with assigned person clinician for each
  patient
• Appointments scheduled to meet standards in items
  2-6 in 1A
• Language services for patients with limited
  English proficiency

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Achieving Must Pass

• Organizing Clinical Data (2D)
• 25-49 of records of patient seen in the past 3
  months include at least 3 tools with information
  documented
• Problem lists
• List of OTC meds, supplements, alternative
  therapies
• Prescription medication list (chronic short
  term)
• Structured template for age-appropriate risk
  factors (at least 3)
• Structured template for progress notes

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Achieving Must Pass

• Identifying important conditions (2E)
• The practice identifies one (1) item from the
  list
• Practices most frequently seen diagnoses
• Most important risk factors in the practices
  population
• Three conditions that are clinically important in
  the practice's patient population (important for
  3A)

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Achieving Must Pass

• Guidelines for Important Conditions (3A)
• The practice adopts and implements evidence-based
  treatment guidelines for 1st and 2nd clinically
  important condition identified in 2E

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Achieving Must Pass

• Self management support (4B)
• 25-49 of the patients seen in the past 3 months
  have at least 3 activities from the list
  documented
• Assess patient preferences, readiness to change
  and self-management abilities
• Provide educational resources in the language or
  medium that the patient understands
• Provides self-monitoring tools or personal health
  record
• Provides or connects patients to self-mgt
  programs
• Provides or connects patients to classes or
  educational programs
• Provides or connects patients to other
  self-management resources where needed

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Achieving Must Pass

• Test tracking and follow-up (6A)
• The practices does 3 types of tracking and
  follow-up
• tracks lab tests ordered or done within the
  practice until results are available to the
  clinician, flagging overdue results
• tracks imaging tests ordered or done within the
  practice until results are available to the
  clinician, flagging overdue results
• flags abnormal tests bringing them to a
  clinicians attention
• follows up with patients for all abnormal test
  results
• notifies patients of all normal test results

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Achieving Must Pass

• Referral tracking (7A)
• The practice uses a paper-based or electronic
  system to assist in tracking practitioner
  referrals designated as critical until the
  consultant report returns to the practice. The
  practice uses a system that includes at least 1
  of the following information for its referrals
• Origination
• Clinical details
• Tracking Status
• Administrative details

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Achieving Must Pass

• Measures of performance (8A)
• The practice measures or receives data on at
  least one of the following types of performance
  by physician or across the practice
• Clinical process (e.g., of women 50 with
  mammograms)
• Clinical outcomes (e.g., HbA1c levels for
  diabetics)
• Service data (e.g., backlogs or wait times)
• Patient safety issues (e.g., medication errors)

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Achieving Must Pass

• Reporting to physicians (8C)
• The practice reports on performance on the
  measures in 8A and 8B EITHER across the practice
  or by individual physician
• 8B is data about patient experience measures

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B. High Tech conceptsMedsphere

• Allows online access to CHC services
• Commonwealth found 34 43 in 7 countries would
  like electronic access
• Charity Hospital in New Orleans
• 87 could use an online medical history (IMH)
• PHC in Des Moines
• 50 said they had online access
• 36 said they would use internet for
  appointments, lab results, med refill request, or
  history taking

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B. High TechMedsphere

• Make appointments online
• Register online
• Receive lab reports online
• Request Rx refills online
• Ask questions online
• Complete a health history online (or in the
  office)

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High TechInstant Medical History (IMH)

• Asks questions we neglect to ask
• Extensive documentation of better histories via
  computer
• Patients feel comfortable

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The CCR Continuity of Care Record

• Contains basic patient info demographic,
  diagnosis, meds, lab results
• Easily transferred among many software types
  Word, EHRs, etc.
• NOT a full EHR, but carries valuable info

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High techModern Registries

• Introduces the concepts of population management
• Interface with most PMSs
• Interface with lab
• Interface with state-wide immunization registries
• In room access possible

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High techModern Registries

• Need not be costly
• Many EHRs do NOT have robust registry functions
• Chronic diseases easy to set up
• Prevention also easy can track
• Immunizations
• Paps and Mammos
• Perinatal care
• Referrals
• And almost anything else you want

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EHRs can be, but are not necessarily, the answer

• 50,000 patient records from 2,500 offices
• 14 of 17 measures no difference
• 2 measures (benzos, no UA) EHR better
• 1 measure (statin use) paper better

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C. High touch concepts

• We must download provider tasks to others
• Team members
• The community
• Technology
• Patients

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C. High touch concepts - team

• With a robust registry
• Plus standing orders
• Plus training
• A team can provide more consistent care than a
  provider working alone

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C. High touch concept - community

• Collaborative activities to
• Increase awareness
• Send a consistent message
• Share costs
• Grocery stores, churches, schools
• Media

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C. High touch concepts - technology

• See notes on Instant Medical History
• Other forms of e-mail communication
• Many patients prefer e-mail
• Takes less clinician time than phone
• CCR

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C. High touch concepts-patients

• We NEED patient involvement in their care
• Cost of care is escalating
• Patient involvement is the only thing that can
  contain costs
• Much of what we do can be done by the patient
  (provide us with medical history, find answers to
  questions, self care of common illness URIs)
• Much of what we need must be done by the patient
  (diet, exercise, substance use, etc.)

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C. High touch concepts-patients(cont.)

• BUT, IOM reported that up to half of adults may
  not have the literacy skills needed to function
  in a health care environment
• The average score on a 6 item test of reading a
  simple food label was 3.4 for the Spanish
  language version, 1.6
• Health literacy is more complex than simple
  literacy

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The 15 minute acute care visit

• It is not reasonable to expect our clinicians to
• Manage literacy issues
• Manage their population of diabetics
• F/U on paps, mammos, immunizations, etc
• Take complete histories
• Monitor potential adverse drug issues
• Etc.

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The more you can move demand away from the
office visits, the more time youll have to deal
with patients who really need personal
interaction.Donald Berwick, MD
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So how do we get to where we need to be?

• It will not be easy.
• And it must be done.

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II. Lean redesign

• From Henry Ford to Deming to Japan to Toyota to
  America. And in many forms with many
  proselytizers.
• Goal is to improve VALUE of services
• Value is the product of efficiency and quality
• There is a huge volume of literature and many
  consultants. There is NO excuse not to know how
  to make change in your systems.

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II. Lean RedesignThis is not a project. This
is a new way of life

• Concepts
• Strong leadership Board, CEO, CMO, CFO
• Self directed teams, rewarded for success and
  innovation
• Eliminate waste
• Improve quality
• Then, only after human waste is eliminated, do we
  add technology

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II. Lean redesign access (efficiency)

• Timely access via efficient flow, and also
  multiple access routes (in person, as well as
  electronic, phone appointments, non-provider team
  members, community resources)
• Lower cost by reducing unnecessary visits allow
  less trained staff to provide quality services
  via protocols
• and patient self-management

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II. Lean redesign - quality

• Requires data
• Treating populations, not just individuals
• Reducing errors via data, and redesign of systems
• Need for new skills in data use
• Huge challenges with low health literacy

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II. Lean redesign - quality

• Allowing self-management and improved health
  literacy. Developing relationships.
• Provide visit summaries
• Allow electronic access to care and information
• Engage alternative teachers interpreters,
  community agencies, churches, grocery stores,
  schools
• Behavioral coaches

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Finally, how do we pay for it all?

• IANEPCA study
• 5,500 diabetics in Iowas state-wide registry
• Lowered A1C from 8.3 to 7.7
• Saved 4.1 million, cost 500,000
• All savings accrued to insurers and the
  federal/state governments
• But, they are listening

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Paying for it

• Pay for performance
• Medicare not yet an option for CHCs
• Wellmark in Iowa pays for control of diabetes
  htn, plus generic prescribing
• NCQA announced criteria and scoring for medical
  homes
• PFP may only be an interim step
• Commonwealth, and many others are urging reforms

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Paying for it

• Blended payments, especially to hospitals some
  fee for service, some incentive, and some
  capitated
• May force hospitals and specialists to work with
  primary care
• We have been able to introduce the concept of the
  medical home into Iowas reform activities

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How to start

• Pick one thing youve heard at this meeting that
  excited you, and implement it!!

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Its not what we know that gives us trouble,
its what we know that aint so.

• Attributed to Mark Twain, among others.