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VA NWI & V23 Medical Home Pilot
Michael S. Hein, MD, MS, FACPMedical Director, VA Midwest Health Care Network, V23Primary Care and Specialty Medicine Service LineMinneapolis, MN
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Existing Outreach Clinics
Planned Outreach Clinics
VISN 23
VISN 23 Data Summary
• FTEE 11,196• Patients Served 290,485• Women Veterans Served 18,434• Outpatient Visits 2,514,579• Budget $1,987,592,774• Medical/Surgical Average Daily
Census (ADC) 300.2• Psychiatry ADC 52.2• Community Living Center ADC
560.5• Domiciliary ADC 181.9• PRRPT ADC 90.8
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• Health Care Systems 8
• CBOCs 44• Outreach Clinics 2• Vet Centers 14
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EOFY 08 VISN VetPop, Enrollment, Market Share and Patients
VeteranPopulation (Projected)
Enrollees(Actual)
Enrollment Based Market Share
(Enrollees to VetPop)
Patients(Actual)
1,025,564 384,225 36% 290,485
FY07 Enrollees and Patients Urban, Rural or Highly Rural
Enrollees Patients
Urban Rural Highly Rural
% Rural (R+HR)
Urban Rural Highly Rural
% Rural (R+HR)
139,082 224,465 26,084 64% 92,250 157,812 19,015 66%
Veterans
Nebraska-Western Iowa HCS
VA - Grand Island, Nebraska (Central) Integrated Health System (VANWIHCS) GRI, Omaha, Lincoln and 5 CBOC’s ~ 45,000 PCP
patientsRural Community – pop. 45,000Serves
Western and Central Nebraska Northern Kansas
Grand Island ~ 13,000 patientsAdditional services: Nursing Home, Therapy,
Mental Health, Residential Treatment, two CBOC’s, Pharmacy, Lab, Radiology
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Joint Principles of the Patient-Centered Medical Home
AAFP, AAP, ACP, AOA
Ongoing relationship with personal physician
Physician directed medical practiceWhole person orientationEnhanced access to careCoordinated care across the health systemQuality and safetyPayment
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Primary Care in the VA
EMR (CPRS) – Fully Integrated; ‘Paperless’Pharmacy Clinics – Clinical PharmacistsChronic Disease Management (Wagner Model)1.0 – 3.0 (2.2) PC Support Staff to 1.0 Provider
FTEUbiquitous Clinical Metrics, including HEDISCAHPS Satisfaction/Experience ScoresCosts – Pharmacy, Lab, Imaging, Clinical ServicesIntegrated (co-located) MH servicesPatients Assigned to PCP: Max Panel = 1200
Medical Home Pilot Time Frame
Conceived Spring of 2008 Proposal for local Innovation Grant – Approved Imbedded project into IHI Triple Aim – Phase II
June 2008, Team Formation and Planning Begins
September 1, 2008, PCMH Clinic ‘opens’Spread to next core teams – September 2009
Inspiration: Quality
Delvin McMillian, 28, a retired airman from Bessemer, Ala., spins away from his pursuers in a quad rugby game at the 28th National Veterans Wheelchair Games, held July 25 through 29
(2008) in Omaha, NE.Photo by David E. Klutho, Sports Illustrated
The Core Team (Micro-Clinic)
Clerks/Schedulers x 2LPN x 3 (4)RN x 1Providers x 5 (2.9 PC FTE)
3 x MD 1 x PA, 1 x APRN
~ 2,800 patientsStaffing ration = 2.0 to 2.3 FTE/PC FTE
The Team (clinic-wide)
Chronic Disease Management Nursing (Wagner)
EMR (CPRS) support staffData AnalystSocial Work*Clinical Pharmacy*Mental Health – partially integratedLeadership - Nursing, Administrative, ClinicalNewly added – Co-management Office
NWI
Core Team-1
(2800)
Core Team-2
(4200)
Core Team-3
(1000)
CBOC-NP
(3000)
CBOC-H
(2000)
Example Medical Home – NWI Grand IslandExample Medical Home – NWI Grand IslandExample Medical Home – NWI Grand IslandExample Medical Home – NWI Grand Island
HBPC
(75)
Clinical Microsystems GRI – Medical Home
(Approx. no. of Patients)
TEAM, SYSTEM REDESIGN, MEDICAL HOME PRINCIPLES
Approach
Constructing Exceptional Primary Care
Team Development and Function
Roles and ResponsibilitiesConflict ResolutionEffective and Safe CommunicationPersonalities – Strengths AssessmentDeveloping a Shared Charter/VisionWorking together
Planning, Implementation, System Redesign
Measurement of ‘Team’
System Redesign at the Front Line
PDSA Rapid Cycle ImprovementBasic LEAN principles – Flow mapping,
measuringWeekly Data Driven DecisionsOpen Access – Reinforcing principlesContinuous Panel ManagementWeekly (1-hr) Performance-based MeetingsData Acquisition and Presentation
Time
Pre-training and Education Weekly to bi-monthly ½ to 1 day sessions (3 months)
Weekly Team MeetingsQuarterly BreakoutsDaily Decisions
Care Management and Coordination Non-face to face care frees up some clinic time
Open Access Scheduling Continuously and rigorously applied
Daily Huddles
Performance
19
20
21
22
23
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The Use of Data
What you measure = how you will ActTimely – frequently enoughActionable – team knows what it meansAccurate – not flawless, but reasonable
Continuously Maturing
Measurement Is it measuring what you want to change? Is it sensitive enough to show change? Is it measuring patient-centered view, or health
system view?
Key Lessons Learned (ing)
Measuring Team Dynamic – Performance
Leadership Good Data in the Hands of
Good People High Performing Team
Dynamic – Limited/Cyclical Nutting et.al. NDP and
“Adaptive Reserve” Time – Commerce of the
Medical Home We Were not Patient-
Centered Enough
What’s Next – National/Regional
History of Primary Care in the VA – 10 year Pulling all of the pieces together
National and Regional (VISN) efforts Universal Services Task Force Report Care Coordination and Chronic Disease Management National Implementation System Redesign at the Front-line Team Dynamic and Function
What’s Next - Local
Spread2 patients on the Core Team weekly meetings
Or a patient council
Coordination of Care – Dual Care FocusContinuous Learning – Working in TeamMeasurement (drives change): Health, Cost,
Patient Experience Team Function/Dynamic “Hominess”
Unsolicited Advice
The principles of Medical Home should guide action
Create a multidisciplinary high performing team Share a Vision that is focused on Quality and Safety
Be knowledgeable about process, flow, and improvement science => gained efficiencies.
Pick the ‘low hanging fruit’ – measureInvolve patientsBe data drivenCelebrate SuccessesLearn, evolve, and don’t avoid ‘failure’
Advice"If you're not failing every now and again, it's a sign you're not doing anything very
innovative.“
Woody Allen
References
Nutting, P., et.al. Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home. Ann Fam Med 2009;7:254-260.
Reid, R.J., et.al. Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation. Am J Manag Care. 2009;15(9):e71-e87.
C00ley, W.C., et.al. Improved Outcomes Associated with Medical Home Implementation in Pediatric Primary Care. Pediatrics 2009;124;358-364.