Ensuring Access to a Modern, Medical Home: The Role for a Primary Care Extension Program in Health Reform

1. Ensuring Access to a Modern, Medical Home: The Role for aPrimary Care Extension Program in Health Reform Society of Primary Care Policy Fellows Kevin Grumbach, MD Department of Family & Community Medicine University of California, San Francisco April, 2009

2. 3° Care 3° Care 2° Care 2° Care 1° Care 1° Care Senator Daschle, Senate HELP Ct Confirmation Hearing Jan 8, 2008: “Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out.” … “We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.”

3. GAO report Feb 2008: • “Ample research concludes in recent years that the nation’s over reliance on specialty care services at the expense of primary care leads to a health system that is less efficient…research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings.”

4. The Crumbling Primary Care Infrastructure • Plummeting numbers of new physicians and PAs entering primary care • Primary care shortages throughout US • Growing problems of access to primary care and “medical homelessness”

5. April 5, 2008 In Massachusetts, Universal Coverage Strains Care Dr. Katherine J. Atkinson of Amherst, Mass., has a waiting list for her family practice; she has added 50 patients since November.

6. Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates Bodenheimer T. N Engl J Med 2006;355:861-864

7. Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists Bodenheimer T. N Engl J Med 2006;355:861-864

9. Why Not Primary Care? • Pre-medical School Factors • Underlying personality disposition, career aspirations • Educational Environment • Practice Environment • Compensation • Manageable, supportive work environment

10. Health care reform will not succeed in its objectives of achieving more affordable, accessible, effective, equitable care without investment to rebuild the crumbling primary care infrastructure

11. A Comprehensive Federal Initiative to Revitalize Primary Care • Training pipeline • Physician payment reform • Infrastructure investment and facilitating practice redesign • Research

12. A 20th Century Model of Primary CareIs Not Meeting the 21st Century Needs of Either Patients or Primary Care Clinicians

13. The New Math of the 15 Minute Primary Care Visit • A primary care physician with a panel of 2500 average patients would spend: • 7.4 hours per day to deliver all recommended preventive care [Yarnall et al. Am J Public Health 2003;93:635] • 10.6 hours per day to deliver all recommended chronic care services [Ostbye et al. Annals of Fam Med 2005;3:209]

14. PCP Burn Out “Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stay still.” Morrison and Smith, BMJ, 20001

15. Problems in Clinical Performance • 27% of patients with HTN adequately controlled • 54% of diabetics have Hgb A1c > 7.0 • 14% of patients with CHD have LDL levels in targeted range • Half of smokers counseled about smoking cessation by their physician

16. Transforming the Practice of Primary Care to Create Modernized, High Performing, Patient-Centered Medical/Health Homes • More clinically effective • More patient centered • More efficient and productive • More satisfying work environment

17. AAFP Future of Family Medicine Report,2004“…point the way to a proposed new model of practice for family medicine”Joint Principles of the Patient Centered Medical HomeAAFPACPAAPAOANursing and PA OrganizationsPatient Centered Primary Care Collaborative

18. Tom Bodenheimer, Kevin GrumbachImproving Primary Care: Strategies and Tools for a Better PracticeMcGraw Hill – Lange, 2006

19. Medical/Health Home Innovations • Chronic Care Model and Care Coordination • Planned Care Models • Group Medical Visits • Open Access Scheduling, Patient Cycle Time • Shared Decision Making, Patient Advisory Councils • Links with Community Resources • HIT • Info flowing with patient • Registries • Virtual Visits • Automated Internet or Telephonic Chronic Care/Self-Management Programs • Teams and Teamwork!!

20. We know where we want to go…but getting there is difficult. • Change is hard

21. …especially in most primary care settings • 2/3 of PCPs work in practices of 4 or fewer physicians • Lack of institutional infrastructure to drive and facilitate practice improvement • Not the practice change paradigm of prescribing profitable products

22. But it is possible to modernize and improve! • Recipe for change: • Knowledge exchange, performance feedback, facilitation, and HIT support provided by individuals with whom practices have established trusting relationships over time • Not a one-time workshop or disengaged dissemination of information • Lessons from family farming applied to family doctoring

23. USDA Agriculture Extension Cooperative Service • Partnership between USDA, land grant universities, farmers since 1914 • Extension agents in every US county – local practice “coaches” • Agents linked to regional hub of agriculture department at a land grant university • resource for research evidence on best practices and promising innovations • Extension agents and farmers work collaboratively to solve problems identified by the farmers • Berwick: “one of the most successful innovation-spread programs ever seen in this country”

24. Adopter Categorization on the Basis of Innovativeness Rogers EM. Diffusion of Innovations. New York, NY: Free Press

25. ARRA of 2009 • Health Information Technology Extension Program: • “To assist health care providers to adopt, implement, and effectively use certified EHR technology…, the Secretary, acting through the Office of the National Coordinator, shall establish a health information technology extension program to provide health information technology assistance services to be carried out through the Department of Health and Human Services.”

26. Proposal for a US Primary Care Extension Program HHS State Hubs Local (County) Extension Offices

27. Primary Care Extension Program Goals • Create and sustain local learning communities • Facilitation of primary care practice redesign • Technical assistance in the application of HIT • Staff training for team-based practice • Generate and disseminate research evidence • Support local primary care workforce development • Shared resources across practices (e.g., case managers) • Engage with local public health agencies, community agencies, patients and the public to address local health needs and primary determinants of health

28. Existing Progenitors of Extension Programs:4 Case Studies • The Oklahoma Physicians Resource/Research Network (OKPRN) • The Center for Excellence for Primary Care, the University of California, San Francisco • Community Care of North Carolina • The New Mexico Health Extension Regional Offices (HEROs)

29. http://www.okprn.org/ • 501(c)3 formed in 1994 as a collaboration between the Oklahoma Academy of Family Physicians & the University of Oklahoma Department of Family & Preventative Medicine; now add’l partners • Director, James W. Mold, MD, MPH • > 235 clinicians, 110 sites • Evolved from a traditional PBRN to assume a more proactive role in practice improvement • Mission: • “to provide community physicians with access to information, education, research and technology in ways that enhance their practices and to generate new knowledge through practice-based research”

30. OKPRN extension agents: • “Practice Enhancement Assistants” (PEAs) • Sustained relationship with a group of practices in a locality • PEAs facilitate • practice audits and feedback • patient satisfaction surveys • staff training • “cross-fertilization” of ideas among practices • coordination of quality improvement initiatives • provision of specific materials and resources • practice based research studies

31. UCSFhttp://familymedicine.medschool.ucsf.edu/cepc/ • Founded in 2005 as partnership between UCSF Dept of Family & Community Medicine and Permanente Medical Group • Director, Tom Bodenheimer, MD, MPH • Mission: • “to transform primary care at the regional level and create a model for nationwide reform…[through] a campaign to boldly reform the delivery of primary care across health systems in the San Francisco Bay Area” • Emphasis on practice redesign, innovation and improvement in safety net clinics in SF Bay Area • Links with UCSF CTSA Community Engagement Program for translational research and implementation science

32. CEPC extension agents • “Clinic Coaches” • Sustained relationship with clinics to facilitate practice improvement • Collaborative model • Training in team-based care • Audit and feedback • Sharing of best practices

33. Established in 1998 under NC Medicaid Program waiver Mission: “to bring together providers to cooperatively plan for meeting patient needs and to strengthen the community health care delivery infrastructure” 14 geographically-based 501(c)3 networks, >3,000 PCPs Emphasis on establishing medical homes for Medicaid beneficiaries and supporting proactive care by risk stratification, disease management, case management and access management Community PCPs, county health departments, social services, hospitals, universities, AHEC http://www.communitycarenc.com/

34. CCNC extension agent: • Nurse and social worker case managers, hired by network and deployed to multiple practices • Monthly care coordination payment to PCPs with requirement for regular data reporting • Independent evaluations: $2 saved for every $1 spent

35. New Mexico Health Extension Regional Offices (HEROs)http://hsc.unm.edu/community/och.shtml • Recently established • Community Oriented Primary Care and Population Health emphasis • Builds on existing USDA Extension Program offices

36. New Mexico HEROs • Community-based Health Extension offices and Agents across the state charged with linking community needs with UNM Health Science Center resources • Campus-based programmatic support to respond in a timely way to community requests and to provide special support in community-identified priority areas • “County Health Report Cards” guide interventions to address the primary determinants of health and illness, including local workforce development

37. Organizational Structure for PC Extension Program • Lead federal office or agency • State level • Required: • State government administrative authority (e.g., State Health Department) • University hubs with centralized expertise and resources to support local offices • Additional possible state level partners: • AHEC, QIO, Professional Societies, PBRNs, Primary Care Association, others

38. Organizational Structure for PC Extension Program • County/local level • Local offices and extension agents to provide sustained, hands-on technical assistance, training, etc. • Community primary care practices, clinics and hospitals; other collaborating providers • Involvement of local public health depts, mental health services, pharmacies, social service agencies, community based organizations, patient advocacy groups, etc

39. Where Should the PC Extension Program Reside in HHS? • New Office of Primary Care Reporting to HHS Secretary? • National coordinator for primary care? • National office of primary care transformation? • Office of the National Coordinator for HIT? • Agency Level? • AHRQ? • HRSA?

40. A Vision of an AHRQ Administered Primary Care Extension ProgramCourtesy of Bob Phillips, Robert Graham Center for Policy Studies

41. University Primary Care Departments, State Govt Primary Care Extension ($500m) Agent in every county Help transform practice Learn from innovators Diffuse/translate research Discover Conditions, treatments NIH AHRQ Rapid testing Network ($40m) Rapid payment and practice change testing Clinically effective change Prepare Medicare demos Practice-based Research networks ($40m) Test lab for Extension Research Resource Center Network Infrastructure IT Research Assistants Project managers NIH Liaisons Translational & Clin. Effect. research, dissemination strategy testing, grants, contracts Clinical payment in network what works? what doesn’t? Dissemination learning Dissemination learning New diseases, new treatments CMS (and demos) Workforce QIOs HRSA AHECs CHCs