Post on 26-Mar-2015
transcript
Medical Home and Disease Management:Convergence Synergy
National Medical Home Summit, 2009
Jaan Sidorov, MD, MHSA – Sidorov Health Solutions
Doug Berkson, MPH – Health Dialog
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Agenda
Potential Areas of Collaboration and Synergy in Traditional Disease Management and Patient Centered Medical Home
Lessons from One “Disease Management Organization”: Integrated Care Management (ICM)
Data aggregation and analytics Practice-based care managementMeasurementMedical Neighborhood
Oberservations and Thoughts on Current State of Patient-Centered Medical Home
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1. Data Aggregation and Analytics
2. Reach and Engage
4. Measurement 3. Intervention
Integrated Care Management:New Model (Medical Home?)
Traditional Disease Management ModelTraditional Disease Management Model Vendor primarily responsible for all components
Integrated Care Management ModelIntegrated Care Management Model Providers/Practices may take role in any or all components
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ICM and Medical Home Overlap
PPC 1: Access and Communication
PPC 2: Patient Tracking and Registry Functions
PPC 3: Care Management
PPC 4: Patient Self-Management Support
PPC 5: Electronic Prescribing
PPC 6: Test Tracking
PPC 7: Referral Tracking
PPC 8: Performance Reporting and Improvement
PPC 9: Advanced Electronic Communications
NCQA Standards Medical Home Standards
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1. Data Aggregation & Analytics: Registries are not enough…
• Creating Actionable Information from Data
• Aggregate data across sources, practices and health plans
• Utilize predictive models for risk identification and stratification
• Create a robust population management tool
Last Name
First Name ID # Age Sex
Chronic Condition(s)
1 2 3 1 2 3 PCP Visits Spec. Visits Admits Total Inpatient Outpatient Rx
Risk Scores Quality Gaps Utilization History Cost History (by bucket)
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2. Reach & Engage
Traditional Model− Sophisticated engagement
technologies and strategy Community Grid Outbound calls Interactive Voice Response Mail Email
Integrate Care Model – Practice-based− Well-established relationships
− Point-of-care engagement
− Direct referrals
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3. InterventionA nurse in the office with a phone & chronic condition disease guidelines is not enough…
• Integrated Care Management: physician-based and/or directed• Care Managers/Health Coaches can be practice-based or remote-
based (“hybrid” model)
• Training • Motivational interviewing, & behavior change theory
• Chronic condition management
• Care coordination and transitions
• Shared-decision making
• Infrastructure and Tools • Technology platform – activity tracking and content functionality
• Decision aides for Preference Sensitive Conditions
• Evidence-based education and self care materials
• Implementation & Operations
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4. Measurement: Quality alone is insufficient.
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4. Measurement - it’s not just about what happens in primary care…
Primary CarePrimary Care
Cardiologist E$7,456
Cardiologist E$7,456
Cardiologist D$5,508
Cardiologist D$5,508
Cardiologist C$4,749
Cardiologist C$4,749
Cardiologist B$4,074
Cardiologist B$4,074
Cardiologist A$2,557
Cardiologist A$2,557
Endocrinologist A$2,203
Endocrinologist A$2,203
Endocrinologist B$2,900
Endocrinologist B$2,900
Endocrinologist C$3,161
Endocrinologist C$3,161
Endocrinologist D$3,591
Endocrinologist D$3,591
Endocrinologist E$4,702
Endocrinologist E$4,702
Hospital A$7,244
Hospital A$7,244
Hospital A$9,777
Hospital A$9,777
Hospital A$10,767
Hospital A$10,767
Unwarranted Variationin
Quality – Preference - Efficiency
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4. Measurement – from the Medical Home to the Medical Neighborhood
Medical Home-----------------------
Coordinated Primary Care
Medical Home-----------------------
Coordinated Primary Care
Cardiologist A$2,557
Cardiologist A$2,557
Endocrinologist A$2,203
Endocrinologist A$2,203
Hospital A$7,244
Hospital A$7,244
• High Quality• Patient preferences • Efficient care• No more than necessary
High Performing Community
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Agenda
Potential Areas of Collaboration and Synergy in Traditional Disease Management and Patient Centered Medical Home
Lessons Learned by One “Disease Management Organization” Utilizing data aggregation, analytics/health informatics, and
health coaching to support Medical Homes: Data aggregation and analytics Practice-based and/or Physician-directed care
management Measurement PCMH in the context of Unwarranted Variation
Observations and Thoughts on Current State of Patient-Centered Medical Home
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Observations and Thoughts on the Current State of Medical Homes
• Fanfare → Scrutiny → Disappointment → Reality
• DM and PCMH may have differing timelines
• Many models, few Medical Homes
• Most current pilots/demos look more like P4P
• Insufficient reimbursement
• Health Plans
• Employers
• Variable recognition or embracement by providers of the degree of change & collaboration required for transformative “next generation” Medical Homes
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Questions?