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West Virginia wants PCMH Level Care Paul Grundy MD, MPH IBM International Director Healthcare Transformation Paul Grundy, MD, MPH, FACOEM, FACPM  IBM Director Healthcare Transformation President Patient Centered Primary Care Collaborative Trip to Denmark  July 10 2009
Who was the  Shooter’s Doctor? Away from Episodes of Care - FFS  Population management !! Accountability  !!
If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH)  The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians. A system integrator a place where data is aggregated, understood and  held accountable  at the level of the individual patient -- THAT IS PCMH.  In fact, cost reduction will often be associated with better outcomes. The Big Idea: How to Solve the Cost Crisis in Health Care by  Robert S. Kaplan  and  Michael E. Porter    Sept 2011 Harvard review
Just Out  ,[object Object],[object Object],[object Object],2010 2011  Adults (18-64) ER visits  -6.6% -9.9% Primary care sensitive ER Visits  -7.0% -11.4% Ambulatory care sensitive Hospitalizations  (per 1,000) -11.1% -22.0%
The Cause? Mostly due to  unregulated fee-for-service payments and an over reliance on rescue/specialty care . This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame -  it is the failure of the deliver system !!” -  Unaccountable Care Organizations * Peter A. Muennig and Sherry A. Glied  Health Affairs  Oct. 7, 2010   Dubuque ,  Iowa   WV 2011
Deaths per 100,000 population* U.S. Lags Other Countries:  Mortality Amenable to Health Care Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,”  Health Policy,  published online Sept. 12, 2011. The Bottom Line  If the U.S. had achieved levels of amenable mortality seen in the three best-performing countries—France, Australia, and  Italy —84,300 fewer people under age 75  would have died last year .  Instead we focused on Rescue Care
The West Virginia Plan   ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Sec of HHS Michael Lewis MD PhD  Commissioner  of Public Health, Marian Swinker, MD, MPH
WV HEALTH IMPROVEMENT INSTITUTE ADOPTION OF ELECTRONIC HEALTH RECORDS Develop proposed mechanisms to accelerate adoption of electronic health records in West Virginia MEASUREMENT Create a forum of alignment of measures across stakeholders to facilitate  reporting SELF MANAGEMENT SUPPORT To align and improve access to resources and best practices to improve the self-activation capacity of all patients EDUCATION  OF THE PROVIDER COMMUNITY To develop a system of provider engagement to accelerate Medicaid Transformation and assist physician practices with migration to AMH PAY FOR PERFORMANCE To provide guidance on the deployment of a P4P program as a model for the State QUALITY COLLABORATIONS To support a focused collaboration of key stakeholders on improving quality, building on past initiatives Member Education Healthy Rewards Advanced Medical Homes Advanced Medical Homes Pay 4 Performance Evidenced Based Medicine Health Information Systems Electronic Health Information Provider Technology Incentives OTHER RELEVANT INITIATIVES WV HIN – WVMI - OTHERS
Electronic Health Records “ A team approach to care…utilizing advanced information systems (including a standardized electronic health record); redesigned, more functional offices, and a whole-person orientation that focuses on quality, safety and care provided in a community context.” 129 Clinicians NCQA certified PCMH practices ( ZERO Morgantown)  Advanced Medical Home
And Today in West Virginia Medical Homes Avoidable emergency room visits continue downward trend, seven percent better than market. Following evidence-based medicine continues to improve, six percentage points better than market. Medical cost trend is more than seven percentage points better than market. Diabetes is better controlled, will improve long-term health and lower medical costs.
Don’t handle your care needs in a  BAD MEDICAL NEIGHBORHOOD!!   Unaccountable care, lack of organization,  DO NOT GO THERE ALONE!!  Be wise when you pay for care,  KNOW WHAT YOU BUY!! BEST HEART SURGERY  !!!!
The Quadruple Aim = MU, PCMH & ACO   Readiness, Experience of Care, Population Health, Cost Population Health System Integrator Patient Experience The System Integrator  Creates a partnership across the medical neighborhood  Drives PCMH  primary care redesign Offers a utility for population health and Financial management Per Capita Cost Readiness
The Foundation for population health needs A long-term  comprehensive  relationship with a  Personal Physician  empowered with the right tools  and  linked  to their care team.
The Joint Principles: Patient Centered Medical Home ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
If you scan the world for value based healthcare you will find a common element: a relationship-based team with a  project manager!  A  comprehensivist  that can command and control in an accountable system with DATA!!  So  simple! So  much!
Powerful Engine for transformation Let me put this in WV  terms… Compressive vs Episodic Integrated Accessible Coordinated “ Opportunities to expand access to primary care, build the health care workforce, and improve prevention and quality and attract jobs.”  Improve the care of the population while controlling costs A “medical home” for patients, emphasizing primary care and make WV a business destination jobs .  Community networks capable of managing recipient care with local systems that improve management of chronic  illness in both rural and urban settings
West Virginia Medicaid and employers –Value based purchasing means ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Large Employers Partner With Medicaid CCNC  New Game Changer “ Aug. 29 (Bloomberg) -- GlaxoSmithKline Plc is giving its privately insured U.S. workers PCMH level Care Via CCNC  health-care network that uses primary care doctors to track patient use of specialists and hospitals.  Community Care North Carolina  Patient-Centered Medical Home model.  It provides a comprehensive, team-based model of healthcare delivery. This model drives out variability by implementing standards for all aspects of primary care services.  CCNC  team ensures that care is all-inclusive and integrated with all other care provided within our system.  Each patient will be assigned to a Medical Home, led by one’s primary care physician. The patient is a part of that team as well as a nurse educator, a care coordinator, and other  support staff , all linked into and supporting the patient’s health.
Reinventing Medicaid with PCMH    findings are Outstanding ,[object Object],[object Object],[object Object],[object Object],Citation --  M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results,"  Health Affairs , July 2011 30(7):1325–34.  The Bottom Line in Medicaid (AS WV discovered already)  PCMH starting to show an impact in access to care, quality, and cost control .
8 Source: Health2 Resources  9.30.08 Defining the Care  Publically available information  ,[object Object]
    Medical Home Model Model adapted from the NNMC Medical Home ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Enhancing Health and the Patient Experience Patient is the center of the Medical Home Population   Health  Patient-Centered  Care Refocused Medical Training Patient & Physician Feedback Advanced IT Systems Access to Care Team-Based  Healthcare Delivery Decision  Support Tools
Public Health Prevention Specialists PCMH in Action  Vermont “Blueprint” model  Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention   HEALTH WELLNESS Hospitals PCMH PCMH Health IT  Framework Global Information Framework Evaluation  Framework Operations A Coordinated  Health System Mental health  PCMH
Vermont Financial Impact 2009 2010 2011 2012 2013 Percentage of Vermont population participating 6.7% 9.8% 13.0% 20.0% 40.0% Participating population 42,179 61,880 82,332 127,045 254,852 # Community Care Teams 2 3 4 6 13
Smarter Healthcare… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Outcomes  of Implementing Patient Centered Medical Home Interventions:  A Review of the Evidence from Prospective Evaluation Studies in the US,  K. Grumbach & P. Grundy, November 16 th  2010.
 
 
Payment reform requires more than one method,  you have dials, adjust them !!! MAINE IS !!  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
OPM $39 Billion Book with Accountable Care Patient at the center  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
CMS New Comprehensive Primary Care Initiative   Risk-stratified care management : Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.  Access and continuity:  Primary care practices must be accessible to patients on a 24/7 basis Planned care for chronic conditions and preventive care Patient and caregiver engagement: Coordination of care across the medical neighborhood.
Where do you train the WV Workforce?  There are examples of at least a few "high performing" Health Professional schools that support team based coordinated care delivery SELECT AND SUPPORT THESE … Requires a Smarter Healthcare Workforce OR ?
 
Recommendations  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Patient Centered Medical home talk at WVU

  • 1. West Virginia wants PCMH Level Care Paul Grundy MD, MPH IBM International Director Healthcare Transformation Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare Transformation President Patient Centered Primary Care Collaborative Trip to Denmark July 10 2009
  • 2. Who was the Shooter’s Doctor? Away from Episodes of Care - FFS Population management !! Accountability !!
  • 3. If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH) The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians. A system integrator a place where data is aggregated, understood and held accountable at the level of the individual patient -- THAT IS PCMH. In fact, cost reduction will often be associated with better outcomes. The Big Idea: How to Solve the Cost Crisis in Health Care by  Robert S. Kaplan  and  Michael E. Porter   Sept 2011 Harvard review
  • 4.
  • 5. The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care . This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system !!” - Unaccountable Care Organizations * Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010 Dubuque , Iowa WV 2011
  • 6. Deaths per 100,000 population* U.S. Lags Other Countries: Mortality Amenable to Health Care Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011. The Bottom Line If the U.S. had achieved levels of amenable mortality seen in the three best-performing countries—France, Australia, and Italy —84,300 fewer people under age 75 would have died last year . Instead we focused on Rescue Care
  • 7.
  • 8. WV HEALTH IMPROVEMENT INSTITUTE ADOPTION OF ELECTRONIC HEALTH RECORDS Develop proposed mechanisms to accelerate adoption of electronic health records in West Virginia MEASUREMENT Create a forum of alignment of measures across stakeholders to facilitate reporting SELF MANAGEMENT SUPPORT To align and improve access to resources and best practices to improve the self-activation capacity of all patients EDUCATION OF THE PROVIDER COMMUNITY To develop a system of provider engagement to accelerate Medicaid Transformation and assist physician practices with migration to AMH PAY FOR PERFORMANCE To provide guidance on the deployment of a P4P program as a model for the State QUALITY COLLABORATIONS To support a focused collaboration of key stakeholders on improving quality, building on past initiatives Member Education Healthy Rewards Advanced Medical Homes Advanced Medical Homes Pay 4 Performance Evidenced Based Medicine Health Information Systems Electronic Health Information Provider Technology Incentives OTHER RELEVANT INITIATIVES WV HIN – WVMI - OTHERS
  • 9. Electronic Health Records “ A team approach to care…utilizing advanced information systems (including a standardized electronic health record); redesigned, more functional offices, and a whole-person orientation that focuses on quality, safety and care provided in a community context.” 129 Clinicians NCQA certified PCMH practices ( ZERO Morgantown) Advanced Medical Home
  • 10. And Today in West Virginia Medical Homes Avoidable emergency room visits continue downward trend, seven percent better than market. Following evidence-based medicine continues to improve, six percentage points better than market. Medical cost trend is more than seven percentage points better than market. Diabetes is better controlled, will improve long-term health and lower medical costs.
  • 11. Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!! Unaccountable care, lack of organization, DO NOT GO THERE ALONE!! Be wise when you pay for care, KNOW WHAT YOU BUY!! BEST HEART SURGERY !!!!
  • 12. The Quadruple Aim = MU, PCMH & ACO Readiness, Experience of Care, Population Health, Cost Population Health System Integrator Patient Experience The System Integrator Creates a partnership across the medical neighborhood Drives PCMH primary care redesign Offers a utility for population health and Financial management Per Capita Cost Readiness
  • 13. The Foundation for population health needs A long-term comprehensive relationship with a Personal Physician empowered with the right tools and linked to their care team.
  • 14.
  • 15. If you scan the world for value based healthcare you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system with DATA!! So simple! So much!
  • 16. Powerful Engine for transformation Let me put this in WV terms… Compressive vs Episodic Integrated Accessible Coordinated “ Opportunities to expand access to primary care, build the health care workforce, and improve prevention and quality and attract jobs.” Improve the care of the population while controlling costs A “medical home” for patients, emphasizing primary care and make WV a business destination jobs . Community networks capable of managing recipient care with local systems that improve management of chronic illness in both rural and urban settings
  • 17.
  • 18. Large Employers Partner With Medicaid CCNC New Game Changer “ Aug. 29 (Bloomberg) -- GlaxoSmithKline Plc is giving its privately insured U.S. workers PCMH level Care Via CCNC health-care network that uses primary care doctors to track patient use of specialists and hospitals. Community Care North Carolina Patient-Centered Medical Home model. It provides a comprehensive, team-based model of healthcare delivery. This model drives out variability by implementing standards for all aspects of primary care services. CCNC team ensures that care is all-inclusive and integrated with all other care provided within our system. Each patient will be assigned to a Medical Home, led by one’s primary care physician. The patient is a part of that team as well as a nurse educator, a care coordinator, and other support staff , all linked into and supporting the patient’s health.
  • 19.
  • 20.
  • 21.
  • 22. Public Health Prevention Specialists PCMH in Action Vermont “Blueprint” model Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention HEALTH WELLNESS Hospitals PCMH PCMH Health IT Framework Global Information Framework Evaluation Framework Operations A Coordinated Health System Mental health PCMH
  • 23. Vermont Financial Impact 2009 2010 2011 2012 2013 Percentage of Vermont population participating 6.7% 9.8% 13.0% 20.0% 40.0% Participating population 42,179 61,880 82,332 127,045 254,852 # Community Care Teams 2 3 4 6 13
  • 24.
  • 25.  
  • 26.  
  • 27.
  • 28.
  • 29. CMS New Comprehensive Primary Care Initiative Risk-stratified care management : Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care. Access and continuity: Primary care practices must be accessible to patients on a 24/7 basis Planned care for chronic conditions and preventive care Patient and caregiver engagement: Coordination of care across the medical neighborhood.
  • 30. Where do you train the WV Workforce? There are examples of at least a few "high performing" Health Professional schools that support team based coordinated care delivery SELECT AND SUPPORT THESE … Requires a Smarter Healthcare Workforce OR ?
  • 31.  
  • 32.

Hinweis der Redaktion

  1. Discuss this from the perspective of the integrator