Transforming Primary Care:What Works and What’s Next

A chartbook created by the staff of

Improving Chronic Illness Care

At the MacColl Institute for Healthcare Innovation

Group Health Research Institute

Supported by The Robert Wood Johnson Foundation

Grant # 053022

I. Primary care in crisis

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Changing demography and practice content

Substantial proportion of ambulatory visits among adults are for chronic illness management1

Chronic problem—routine

Chronic problem—flare-up

All patients 30% 9%

Age 25-44 26% 9%

Age 45-64 37% 10%

Age 65+ 42% 11%

Note: See slide notes for citations in this chartbook or the CD’s Articles & Websites section.3

Greater care complexity

• Studies2,3 estimate that it would take 7.4 hours to deliver all recommended preventive services and 10.6 hours per working day to deliver all evidence-based care for chronic conditions to a primary care panel.

• “These excessive demands contribute to long waiting times and inadequate quality of care for patients.”4

• Concern about one’s ability to manage complex, chronically ill patients may contribute to driving career choice away from primary care.

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Quality of current primary care

Public Physicians Policymakers

People with chronic conditions usually receive adequate medical care

48% 45% 22%

• Patients with major chronic illnesses receive recommended care about half of the time.5

• Half of patients leave the doctor’s office without understanding what their physician said.6,7

• These deficits are now perceived by patients, physicians and policymakers.8

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The physician workforce in decline

• The proportion of Internal Medicine residents becoming generalists declined from 55% to 2% within a decade.9

• Income, debt and work hours are all cited as factors.

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A need for major healthcare reform

Percent saying AUS CAN FR GER ITA NET NZ NOR SWE UK US

Only minor changes are needed

23 33 41 18 38 60 42 56 37 47 17

Fundamental changes are needed

71 62 53 51 58 37 57 40 54 50 67

System needs to be completely rebuilt

6 4 6 31 4 1 1 2 7 3 15

Do primary care physicians (PCPs) in the U.S. and elsewhere see the need for major healthcare reform?10

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Primary care’s decline: Does it matter?

• The vast majority of the population prefers a PCP, while 95% of Americans want one practice and/or clinic where doctors and nurses know you, provide and coordinate the care that you need.11

• Countries with better primary care have better health outcomes.12

• U.S. states with higher primary care/population ratios have reduced costs and better quality healthcare.13

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And how will we pay for healthcare?

• The U.S. is currently spending 17% of GDP, the most of any nation.14

• If healthcare spending grows at the current rate, a staggering 119% of the real increase in income over the next eight decades will be consumed by healthcare spending, leaving nothing for other needs.

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What can we do?

• The future of primary care (and our healthcare system) depends upon its ability to improve the quality and efficiency of its care for the chronically ill.

• It will also require a recommitment of primary care to meet the needs of patients for timely, patient-centered, continuous and coordinated care.

• That will require a major transformation or redesign of practice, not just better reimbursement.

• However, such transformations will be difficult to motivate or sustain without payment reform.

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II. What works

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What works – Previous disks in this series

Volume 1: “Tackling the Chronic Care Crisis” explained the Chronic Care Model (CCM) and summarized the evidence base that has developed in the last decade.

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Volume 2: “It Takes A Region” examined the developing evidence base for regional healthcare improvement and proposed a framework to guide community improvement efforts.

Leadership

What works – Previous disks in this series

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What works: Other tools developed by ICIC

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• Visit our website, www.improvingchroniccare.org to learn more about the following tools:*

– We have a practice toolkit, available to download from our website, that is a summary of our lessons learned and a repository of useful tools.

– We also have a toolkit to provide busy clinical practices with a set of tested resources and tools to share with patients and families in the day-to-day management of chronic conditions.

* See the slide notes page for specific URLs.

Success factors

1. Team care – Clinical tasks shared with non-physician staff

2. Information technology – Functions that support healthcare planning and proactive, population based care

3. Planned care – Patient needs identified prior to encounters and systematically addressed

4. Self-management support – Engaging patients as partners in care

What qualities do practices with improved outcomes share?

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For example: Depression Management

• Medical assistant administers PHQ-9

• MD diagnoses depression and initiates treatment

• Population manager enters patient and data in registry

• Care manager follows the patient over time provides self-management support

• Consulting psychiatrist provides advice and care manager and MD

Successful care depends on everyone on the team

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Create a successful team

• Plan and improve care together.

• Define roles and tasks and distribute them among team members.

• Train people for their roles.

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Incorporate improvement into daily work

• Meet briefly and often to review performance and plan PDSA cycles.

• Make improvement a part of the clinical team’s day-to-day thinking and work.

• Communicate regularly with senior leaders to discuss successes and barriers.

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CharacteristicHigh-performingplans

Low-performingplans

P

HbA1c >9.5 20% 49%

Use of aregistry

78% 40% .02

For example: Most of the Medicare plans providing the best diabetes care use a registry.15

Successful teams use a registry

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Why is registry functionality so critical?

• Population management

– Allows practices to monitor entire practice panel and reach out to those needing service.

• Encounter planning and reminders

– Easy access to data on guideline adherence and key indicators facilitates productive interactions.

• Performance measurement

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Successful teams support self-management

• Organize and train team members to provide basic self-management support.

• Identify and use effective self-management support resources in their area.

• Make self-management support a part of every interaction.

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Self-management support must include key community resources

• Encourage patients to participate in effective community programs that provide important services (e.g. exercise, self-management support, smoking cessation, peer support, etc.).

• Form partnerships with key community organizations to support or develop programs.

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What works

• Leadership — Leader attitudes about and level of support for QI a strong predictor of success.

• Financing — Providing financial incentives for transforming practice predicts involvement in QI and perhaps success.

• Effective practice management systems — Must be in place for practices to transform their clinical systems.

Organizational and environmental factors associated with high-quality care

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• Trusted performance measurement is a powerful motivator for practice involvement in QI.

• Networking smaller practices can provide leadership, motivation and support for otherwise isolated practices to engage in QI.

What works

Organizational and environmental factors associated with high-quality care

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• Over the last decade we have worked directly or indirectly with over 1,500 practices in collaboratives

• Teams that use PDSA cycles based on the CCM systematically over time:16

– Usually see process improvement

– May or may not see outcome improvement

– Enjoy their work more

What works: Formal learning structures like breakthrough series collaboratives

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Limitations of breakthrough series collaboratives

• Small percentage of eligible practices participate — usually early adopters

• Reach within a practice organization limited to the most motivated

• Changes often made in ways that are not sustainable

• Can encourage project-based(i.e. time-limited) thinking

Collaboratives have demonstrated positive change, but there are limits:

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III. What’s next: The promise and challenge of the Patient-Centered Medical Home (PCMH)

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The CCM and the PCMH: Complementary models

• Primary care is regarded as a linchpin to current healthcare reform efforts.

• The PCMH is being proposed as a way to rejuvenate primary care.

• The current PCMH model is a combination of the CCM and the Pediatric Medical Home model.

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Understanding the origin of the Patient-Centered Medical Home

• The Pediatric Medical Home concept arose out of frustration with the fragmented care of children with special needs.

• Medical Home model puts the relationship with the PCP and team at the center of a patient’s care, and makes explicit the expectations of the PCP to provide timely, continuous, patient-centered and coordinated care.

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• Both the PCMH and CCM rest on the clinical evidence of practice changes that lead to improvements in patient care and outcomes.

• Both models advocate that every healthcare experience (e.g. visit, referral, admission, etc.) connects the patient back to their PCP.

• Both emphasize and support the patient role in decision-making and care.

Understanding the origin of the Patient-Centered Medical Home

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Key features of a Patient-Centered Medical Home17

• Personal physician – First contact, continuous and comprehensive care

• Team care – Collectively take responsibility for ongoing care

• Whole person orientation – Take responsibility for all patient needs by delivering or arranging care

• Coordinated care – Across all elements of the healthcare system

• Quality and safety – By implementation of CCM, continuous QI and voluntary recognition process

• Enhanced access – Via open scheduling, expanded hours and new options for communication

• Payment – Recognizes value of the PCMH, pays for coordination and electronic communication with patients, and supports IT use

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Is the Patient-Centered Medical Home based on evidence?

• The CCM holds considerable evidence of salutary effects on quality of care.16

• Improved continuity is associated with better healthcare, patient satisfaction and outcomes.18

• Access and coordination are valued by patients, and interventions directed at improving transitional care have improved care and outcomes.19

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What are the goals of the PCMH?

For long-term success and impact, PCMHpractices must:

1. Improve outcomes for patients with major chronic illnesses.

2. Reduce costs through fewer emergency room visits and hospitalizations (especially re-admissions and admissions for ambulatory-sensitive conditions.

3. Improve both patient and provider experience.

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Can these goals be achieved?

• PCMH implemented in one primary care clinic with 10,000 patients

• Compared with two other clinics with similar baseline performance

• One year, in comparison with control clinics, the PCMH clinic experienced:

– Greater improvement in patient experience

– Dramatic reductions in provider burnout and dissatisfaction

– Small improvements in clinical quality across the board

– Significant reductions in avoidable hospitalizations and emergency room and urgent-care visits

– Improvements largely maintained in year two

The Group Health PCMH Pilot20

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What we are learning about implementing the PCMH21

• Practice transformation requires “epic … redesign,” not just incremental changes.

• Even in practices with EMRs, achieving “meaningful use” often requires major educational and technologic intervention.

• Change fatigue is a serious concern.

• To make changes, practices need “adaptive reserve” — leadership, QI time and solid relationships to weather the storm.

• Transformation is local; intervention ideas must be molded to fit local environments.

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What we still need to learn about the elements of the PCMH model

• Practical approaches for making self-management support a routine component of all transactions with patients.

• How best to provide 24/7 access. Which coverage alternatives best meet patient needs and reduce ER and hospital use?

• How best to coordinate care and link to community resources. Which alternatives best meet patient and provider needs and reduce ER and hospital use?

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What we still need to learn about implementation

• Is there a best QI method to support PCMH implementation?

• Is there a best strategy for supporting practices involved in PCMH implementation?

• What practice payment reforms best motivate engagement in transformation?

• What practice payment reforms lead to the most successful and sustainable implementation of the PCMH?

• How important is networking of smaller practices, and what network structures are most successful?

• How do we best measure PCMH implementation and effectiveness?

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Transformation is a Developmental Process21

• It begins with a solid core structure.– Well-functioning clinical and QI teams

– Effective financial management

– Committed leadership

– Functional IT

• Develop or nurture the “adaptive reserve”.

• Try to change both the practice AND the environment in which the practice operates (e.g. the medical neighborhood).– Have to address professional isolation and relationships between primary

and hospital/specialty care

– Try to address financial barriers and incentives with payors

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The structural barriers to overcome becoming a medical home

• Difficulty defining the practice’s “panel”

• Lack of supportive information technology

• Lack of financial incentives

• Lack of hospital or specialist support of care coordination

• Practice isolation from partners and QI infrastructure

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A real opportunity

• There is real possibility of healthcare reform that includes an emphasis on primary care renewal.

• There is strong support for a model (the PCMH) that can improve healthcare and reduce costs.

• There is growing evidence and experience base for transforming practice.

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Thank you to The Robert Wood Johnson Foundation and to all of our partners in improving chronic care over the last decade.

www.improvingchroniccare.org

Continue to find us at:

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