Transforming Primary Care at Group Health Cooperative April 16, 2010, Clarissa Hsu PhD, Center for Community Health and Evaluation part of the Group Health Research Institute QualisHealth Webinar
Transcript
Transforming Primary Care at Group Health Cooperative
April 16, 2010, Clarissa Hsu PhD, Center for Community Health and Evaluation part of the Group Health Research Institute
QualisHealth Webinar
Presenter
Presentation Notes
Thank you so much for inviting us to talk about the evaluation of Group Health’s medical home prototype project. My name is Clarissa Hsu. I am a medical anthropologist by training. And I specialize in evaluating health improvement projects, especially community-based programs and clinical quality improvement. I’m a member of a team called the Center… which is housed at the Group Health Research Institute. I joined the medical home evaluation team a little over a year ago. So while I was not heavily involved in the prototype evaluation when it was underway, I have been very involved in the work around the analysis of the follow up data and the evaluation of the spread of the medical home. I know the spread is a topic of considerable interest. I’ll talk a bit about that at the end of this presentation. However, we don’t have sufficient data at this point on the spread for a presentation at this time. I believe we will be invited back in the future to talk about our preliminary spread findings. So this presentation focuses on the evaluation of what we call the prototype clinic. That is the clinic that was used to figure out exactly what a medical home can and should look like at GH and to see what the possible outcomes might be for converting to a medical home model.
Presentation Goals
• Revitalizing primary care: the medical home imperative
• Defining the medical home at Group Health
• Getting from here to there: implementing practice redesign
• Our medical home learnings
• What’s next at Group Health?
Presenter
Presentation Notes
There are several topics I want to cover during this presentation. First I want to talk about what my colleague Rob Reid has labeled the “medical home imperative.” Basically, why was there a need for the medical home at GH? Next I’ll describe how the medical home was defined at GH. From there I’ll talk about how the redesign was implemented, provide some findings and key learnings and then talk a bit about the spread of the medical home…what’s next for the medical home at GH.
About Group Health…
•Integrated health insurance & delivery system•Founded in 1946•Consumer governed, non-profit•Membership: 628,000 Staff: 9,390•Revenues (2008): $2.8 billion
•Integrated Group Practice• 26 primary care medical centers• 6 specialty systems, 1 hospital•~900 physicians
In order to understand the need for a medical home at GH it is important to have a bit of information about the organization. READ
Revitalizing primary care
Presenter
Presentation Notes
The next few slides lay out why a medical come was needed.
A little history…
•Since its origin, Group Health organized around primary care base
•Declines in financial performance & membership in early 2000s
•Reforms implemented to improve access, efficiency, productivity
•Reforms resulted in a faster “hamster wheel” (Tufano JGIM 2008;23:1778-83. Conrad HSR 2008;43:1888-1905.)
Defined practice populations Multi-disciplinary teamsSpecialty care gatekeeping Salaried physicians
“Advanced access” Same-day appointingLeaner primary care teams Direct specialty accessEHR implementation Secure email messagingRVU-based productivity incentives(Ralston et al, Med Care Res Rev. 2009;66:703-24.)
Presenter
Presentation Notes
Since GH was founded it has been organized around primary care. Some key principles have included having defined practice populations (everyone either chooses or is assigned to a primary care provider or a primary team. Those team were multidisciplinary including MAs, RN, mid-level providers and physicians and at time and clinical pharmacist. Finally primary care providers were the gatekeepers for specialty care. Then in the early 2000’s GH began seeing declines in financial performance and membership. In response a number of changes were made to GH systems to improve access, efficiency and productivity. The Access Initiative was implemented which included…<READ LIST> Result was the providers felt that they were trapped on a hamster wheel that was spinning out of control. In other words, providers were experience incredible job stress and burn out. Many providers were choosing to practice part-time in order to manage stress, others were simply leaving. <GET DEFINITION OF RVU=Relative Value Units are….>
The medical home imperative
Utilization Trends 1997-2005 by Quarter
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ER Visits
Access & Efficiency Reforms
1997 1998 1999 2000 2004 20052002 20032001
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Presenter
Presentation Notes
This slide indicates where the access initiative occurred and you can see a marked increase in specialty visits.
Inpatient & ER Utilization Trends 1997-2005 by Quarter
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1997 1998 1999 2000 2004 20052002 20032001
The medical home imperativeFr
eque
ncy
Presenter
Presentation Notes
This graph focuses in on the three bottom lines of the last graph which are inpatient days, ER visits and inpatient admits. And you can see and increase in both inpatient days and ER visits, which as we know if a trend in the wrong direction for those measures.
Increasing primary care physician burnout
“...the way in which [care] is structured, it has shifted such an increased amount of work onto primary care that it is not sustainable … I’m actually looking to get out of primary care because I can no longer work at this pace.”
“ The burnout rate among my colleagues is huge … those of us that have managed to retain some semblance of balance do it by almost unacceptable levels of compromise, either for ourselves or what we define as good enough care.” (Tufano et al, JGIM 2008;23:1778-83)
Looming primary care workforce crisis
• Many positions unfilled
• Full-time practice is now a rarity
• Primary care MDs retiring earlier than specialists
• Exit interviews show most common reason for separation: high workload
The medical home imperative
Presenter
Presentation Notes
As mentioned earlier the issues of provider burnout became critical. The quotes on this slide illustrate the fact that burnout was getting to the point that physicians were thinking about getting out of primary care. I was doing interviews with providers for another project during this time and I also heard providers talking about stress and overwork. And general sentiments about overwork were translating into a very real work for crisis. GH wasn’t able to fill position, as I mentioned earlier provider who continued were choosing not to work full time. Primary care MD were retiring earlier than specialists and exit interview revealed the high workload as the most common reason for leaving. So clear the situation was unsustainable if GH was going to c
The medical home imperative
There just has to be a better way!
Presenter
Presentation Notes
So clear the situation was unsustainable if GH was going to continue to provide primary care services. And GH started looking for a better way to administer primary care.
Revitalizing primary care
Traditional family practice values
+ 21st century information technology
Supported by consumers, physicians,
health plans, policy makers
The PCMH model:
Whole person care
across lifespan
Personalized, prevention-
focused, coordinated
Until now, little empirical
evidence of its
benefits
Presenter
Presentation Notes
So GH decided to pursue this idea of creating a patient centered medical home. I think most of the people participating today have a sense of what the PCMH includes, so I’ll try to summarize this very quickly just to ensure there is a shared understanding of the foundation on which GH’s medical home was created. <Middle upper> First, it really builds on some core elements of primary care (referred to here as “traditional family practice values”)—which includes making sure the primary care is accessible, comprehensive, coordinated, and continuous. The approach incorporates features of the Chronic Care Model which includes make sure the care is evidence-based, it is focused around a team care, and that performance is regularly measured. and use of information technology. The model has a broad base of support including primary and specialty care professional organizations, hospitals and health systems, health plans, employers, labor unions, consumer advocates, and policy makers. Within the PCMH, primary care clinicians lead multidisciplinary teams and are responsible for delivering and coordinating whole-person (rather than disease-oriented) care over time. A medical home provides expanded primary care that is personalized, focuses on prevention, actively involves patients in making decisions about their care, and helps coordinate all their care and get their health needs met. Applied information on how best to implement the PCMH and on its ability to achieve improved outcomes in real-world settings is lacking and urgently needed.
Revitalizing primary care
Physician - patient
relationship at the core
Coordination & collaboration with patients
Group Health PCMH design principles:
Proactive, comprehensive
care
Patient- centeredaccess
24/7
Efficient, satisfying, effective
Presenter
Presentation Notes
The it came time to design the prototype, five design principles were used, these included: The relationship between the personal care physician and the patient is the core of all that we do. The entire delivery system and the organization will align to promote & sustain this relationship The personal care physician will be a leader of the clinical team, be responsible for coordination and integration of services, and together with patients will create collaborative care plans. Continuous healing relationships will be proactive and encompass all aspects of health and illness. Patients will be actively informed and encouraged to participate in all aspects of their care. Access will be centered on patients needs, be available by various modes 24/7 and maximize the use of technology Our clinical and business systems are aligned to achieve the most efficient, satisfying, and effective patient experiences.
Revitalizing primary care
Panel size
1,8002,300PCMH design:
Clinical teams Desktop time E-technology
Appointments
20 min.
30 min.
Presenter
Presentation Notes
The Medical Home pilot advanced the organization’s primary care model by improving access, enhancing continuity, proactively coordinating care, and engaging patients in their health in the following ways: Reducing panel size (patient load) from 2,300 to 1,800 patients. Lengthening appointment times from 20 minutes to 30 minutes. Expanding staffing in multidisciplinary clinical teams consisting of physicians, physician assistants, nurses, medical assistants, and clinical pharmacists. Improving proactive staff-to-patient contact, including clinical team analysis days before each appointment, pre-visit patient communication as appropriate, and detailed follow up after the visit. Maximizing use of e-health technology and communication, including electronic medical
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
Presenter
Presentation Notes
Based on those design principles three change components were developed. This included: Point of care changes which consisted of things like making sure patients who called could actually speak to someone on their care team (the standard practice was that anyone who called would leave a message and be called back later in the day), increases in the use of secure emails to interact with patients and resolve patient issues, increased phone encouter <Continue reading>. The second set of changes focused on increasing patient outreach. So outreach was increased for the following circumstances. Finally there were management and systems changes that took place that included <READ> They went back to salary only MD compensation.
Planning and evaluation
Presenter
Presentation Notes
The next set of slides outlines the implementation of these components and the accompanying evaluation plan.
PCMH timeline
Presenter
Presentation Notes
Reid, R.J., et al., Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. American Journal of Managed Care, 2009. 15(9): p. e71-87. There is a timeline. <WALK THROUGH IT>
PCMH prototype evaluation
Group Health Research Institute conducted a prospective, before-and-after evaluation comparing Prototype clinic with other Group Health clinics in western Washington
Presenter
Presentation Notes
The evaluation team (which was lead by Rob Reid) designed a prospective, two-group, before-and-after evaluation of the PCMH prototype at Factoria clinic. Using automated clinical and administrative data, the team compared change components at the beginning of the pilot, at the end of the first year, and during the second year with 19 other Group Health clinics in western Washington. These change components included secure email messages between physicians and patients, telephone consultations, and calls to the consulting nurse service.
PCMH prototype evaluation
Patient experience
Staff burnout
Evaluation measures:
Quality Utilization Cost
Presenter
Presentation Notes
The evaluation also assessed quality of care, utilization, and net per-member-per-month costs. Patient experience and staff burnout were gauged with surveys comparing the PCMH clinic with two similar control clinics.
Significantly higher scores for patients at PCMH prototype clinic
Compared to controls:
Difference not significant
PCMH Prototype significantly higher
PCMH Prototype significantly lower
Presenter
Presentation Notes
Patient experience After adjusting for differences in age, education, and self-reported health status, PCMH patients reported significantly higher scores for 6 of 7 patient experience measures after the first year, and for 5 of 7 after year 2. Ratings for helpfulness of office staff were high at baseline and remained so for all clinics. Year 1: Difference between baseline and 12 months Year 2: Difference between baseline and 24 months
25.6%
18.2%
30.4%
25.0%
54.5%
54.2%
10.0%
25.0%
18.8%
25.0%
19.4%
44.4%
-60% -40% -20% 0% 20% 40% 60%
12 month
Baseline
12 month
Baseline
12 month
Baseline
% Patient Care Employees rating as "Moderate/High"
Medical Home Control Clinics
Emotional Exhaustion
Depersonalization
Lack of Personal Accomplishment
**
** p<0.01
Staff burnout
Marked improvement in burnout levels at PCMH prototype clinic at 1 year
Presenter
Presentation Notes
SLIDE #42 – STAFF SURVEY Measured 3 dimensions of burnout with staff survey Emotional exhaustion (feeling burnt up at end of day) Depersonalization (treating people like numbers not people) Lack of personal accomplishments (feeling like you did not personally succeed at work with patients) This slide shows you very promising results comparing med home and control clinics: Almost 50% staff reported moderate to high emotional exhaustion at baseline Substantial reductions at 12 months – <20% at PCMH and no change at control clinics
-75.9%
-61.3%
-56.9%
-54.6% 46.4%
44.4%
66.5%
63.8%
-51.0%
-79.8%
-68.1%
-72.1%
51.0%
53.7%
72.3%
74.9%
-100% -80% -60% -40% -20% 0% 20% 40% 60% 80% 100%
+3.7%
+4.0%
+3.9%
+4.4%
+1.4%
+1.2%
+1.6%
+1.6%
Patient Average
100% Performance
75% Performance
50% Performance
Baseline
12 month
Baseline
12 month
Baseline
12 month
Baseline
12 month
Medical Home Control Clinics
Quality of care
Composite measures based on 22 HEDIS indicators measured for each patient
0.00
0.50
1.00
1.50
2.00
2.50
3.00
Primary CareVisits
Secure MsgThreads
TelephoneEncounters
Specialty CareVisits
ConsultingNurse Calls
ED/UC Visits Inpatient Stays
# vi
sits
per
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yea
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Medical Home Non-Medical Home
UtilizationV
isits
per
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per
yea
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(Note: mean utilization in first year of PCMH implementation estimated with GLM models, log link, Poisson error, adjusting for age, gender and baseline DxCG scores.)
Medical Home (n=8,094) Other Clinics (n=228,510)
*p<.05*
*
*
*
*
*
Costs
$582
$1,140
$238
$566
$1,104
$292
$2,183 $2,174
$0
$500
$1,000
$1,500
$2,000
$2,500
Primary care Specialty care ED/UC Inpatient
Medical Home Control Clinics
(Note: mean PMPM patient care costs for first year of PCMH implementation estimated with GLM models, identity link, Gamma error, adjusting for age, gender and prior year costs.)
Medical Home (n=8,094) Other Clinics (n=228,510)
***
*p<.05 ** p<.001
Takeaways
Patient-centered primary care saves costs by lowering inappropriate use of emergency care and avoiding preventable hospitalizations.
Investment in a medical home can achieve relatively rapid returns across a range of key outcomes.
The Group Health PCMH evaluation provides some of the first empirical evidence of the benefits of the medical home.
Preliminary analysis suggest that improvements during the first year for the most part were maintained during the second year.
The evaluation has led Group Health to spread the PCMH to all 26 of its medical centers.
PCMH evaluation takeaways
Presenter
Presentation Notes
Reid, R.J., et al., Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. American Journal of Managed Care, 2009. 15(9): p. e71-87.
PCMH Spread at Group Health
Virtual Medicine
Care Management
Visit Preparation
Patient Outreach
1. Staged spread of practice change modules
Call Management Team Huddles Standard Mgmt Practices
Enhanced Staffing Model Value-based MD Payment Model
2. Supported by changes to mgmt, staffing, & MD payment
Standardization & Spread using LEAN Techniques & Tools
