Care by design 1 continuum article

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Paul Grundy

Gesundheit & Medizin

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Surgeon General of the Navy VADM Matthew L. Nathan, MC USN Fortunately, we have a way to address this crisis—the Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.

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Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.

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explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967. This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home. The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.

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review the available literature to identify the major challenges and barriers to implementation and adoption of the patient-centred medical home (PCMH) model, topical in current Australian primary care reforms. documents the key challenges and barriers to implementing the PCMH model in United States family practice. It provides valuable evidence for Australian clinicians, policymakers, and organisations approaching adoption of PCMH elements within reform initiatives in Australia.

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Effective integration of specialty practices into medical neighborhoods is likely to require several important environmental precursors. First, a sound infrastructure design can connect PCMHs to the spectrum of surrounding specialty practices. An aligned information architecture will be vital to adequate patient access, care coordination, and communication. Second, a patient centered neighborhood will rely on an organizational culture that supports shared learning and transparency of performance and cost data among participating practices. Third, payment incentives will have to be aligned around shared accountability for outcome and cost. Responsibility for outcomes and total cost of care will have to rest not only with primary care clinicians, but also with specialists who perform(often expensive) procedures and specialty services.The launch of the NCQA’s PCSP recognition program is a sign of a new phase of delivery system reform

Nejm rosenthal april 9 2014

Paul Grundy

Summary -- Patient Centered Medical Home the Necessary Foundation for Accountable Care and Population Management. In the next 10 years, we will be living in 1) mobile world 2) in the middle of an aging and chronic disease epidemic and 3) data. But , we will also have the ability to analyze data in a cognitive way this will do for doctors’ minds what X-ray and medical imaging have done for their vision. How? By turning data into actionable information. Take, for instance, IBM’s intelligent supercomputer, Watson. Watson can analyze the meaning and con-text of human language and quickly process vast amounts of information. With this in-formation, it can suggest options targeted to a patient’s specific circumstances. We need the basic foundation to support this transformation a system integrator where data at the level of a patients flows and is held accountable and that model is the Patient Centered Medical Home. (PCMH) starts to happen when clinicians/ healers step up to comprehensive relationship based care empowered by tools to manage the data and communicate effectively. This move to PCMH level care requires the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system and all of that is power by data made into meaningful information. But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that. The Patient-Centered Medical Home (PCMH) lies at the center of the effort to get at population health, integrated and coordinated care. PCMH is where the Primary care healer leads an organization that delivers clinician-led primary care, with comprehensive, accessible, holistic, coordinated, evidence-based coordination and management. In the USA this is now the standard in the US Veterans Administration and the US Military and under the ACA.

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This is a great example of a community in New Zealand of the interrogation of social services and healthcare. They are changing the demand curve and getting away from “we need more and more resources to see more patients”. The language we use, very deliberately, is “right care, right place, right time”. Once you start getting the whole system to work as one system, it starts flushing out unnecessary expenditure. So you can do more and/or do it better.’ worth a read.

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