Implementing the Guided Care Model of the Medical Home AMGA 2008 Institute for Quality Leadership September 26, 2008

1. Implementing the �Guided Care� Model of the Medical HomeAMGA 2008 Institute for Quality LeadershipSeptember 26, 2008 Professor Chad Boult, MD, MPH, MBA Johns Hopkins Bloomberg School of Public Health Barbara Cook, MD President, Johns Hopkins Community Physicians

2. Guided Care The Economic Engine of the Enhanced Medical Home

3. Guided Care Strategy:To Translate Knowledge to Practice Combine successful innovations Integrate them into primary care Make the model diffusible

5. The Guided Care Model Specially trained RNs based in primary physicians� offices GCNs collaborate with 2-5 physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health care needs Boyd CM, Gerontologist 2007 www.GuidedCare.org

6. Guided Care Nurses� Activities Assess needs and preferences Create an evidence-based �care guide� Monitor patients proactively Support chronic disease self management Communicate with providers in EDs, hospitals, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies in the community Smooth transitions between sites of care Educate and support caregivers Facilitate access to community services

8. Electronic Health Record Creates: Evidence-based �Care Guides� Reminders Provides: Decision support: drug interactions Documentation of encounters

9. Identifying Vulnerable Seniors

10. Effects of Guided Care Higher quality of care Greater physician satisfaction with care High nurse job satisfaction Lower caregiver strain Lower costs of health care 23% ? in insurance payments in pilot test $85,500 annual net savings per nurse in RCT Boult C, J Gerontol Med Sci 2008 Boyd CM, J Gen Intern Med 2008 Sylvia M, Disease Manag 2008 Leff B (in review) Marsteller J (in review) Wolff J (in review)

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12. JOHNS HOPKINS COMMUNITY PHYSICIANS Your Home for Good Health

13. OUR VISION TO BE THE MEDICAL HOME FOR OUR PATIENTS where everyone�s physical, emotional and social well being is valued and all are treated with kindness, competence and respect.

15. WHO WE ARE Part of Johns Hopkins Health System Private, non-profit, primary care organization Network of 17 medical centers spanning 100 mile radius throughout Maryland 143 clinicians 660 support staff

16. WHAT WE DO Patient Care Provide primary and secondary care to over 180,000 Maryland residents. Over 545,000 patient visits annually Teaching Provide practice experience for 50 medicine housestaff, 10 pediatric housestaff and 80 ACIM medical student rotations Research Participate in research initiatives from Johns Hopkins Schools of Medicine, Nursing and Public Health

17. COMPENSATION PLAN 65% of compensation is guaranteed 25% at risk based on productivity 10% at risk based on quality Productivity measured by RVU�s

18. Johns Hopkins Community Physicians Payor Mix Fee for Service 76.3% Medicare 13.9% Medicaid 8.0% Commercial 75.8% Self Pay 2.3% Capitated 23.7%

19. SURVIVING IN PRIMARY CARE There is an upper limit to pushing productivity There is a lower limit of salary expectations; if not met, there is attrition in the primary care specialties There is a breaking point for tolerating bureaucratic hassles in provision of care

20. FUTURE OF PRIMARY CARE Paperwork burden must be lifted Compensation must improve Cognitive expertise of clinicians must be valued Crucial role in managing the care of aging population must be recognized and rewarded.

21. Primary Care in 2008 Wages Work hours Satisfaction Fewer new PCPs More early retirement Growing workforce shortage More chronically ill older patients

22. JHCP�s Interest in Guided Care Quality of care Patients� quality of life Patients� satisfaction with care Providers� professional satisfaction Efficiency in the care of complex patients

23. JHCP�s Experience Selection of four practices: Number of patients age 65+ Space for an RN�s office Geographic proximity to Baltimore Physicians� interest

24. Implementing Guided Care Orientation of physicians and administrators 2 lunch meetings with research team Orientation of the nurse to the physicians, the practice, and community resources GCN course, checklist for on-site orientation Building the Guided Care caseload (55 pts) Care planning sessions: 20-30 minutes/pt Ongoing Guided Care Communication about patients, teamwork

25. Physician Satisfaction Compared to 20 control physicians, 18 Guided Care physicians reported greater satisfaction with 18/20 processes. Some were statistically significant (p < 0.05): Educating family caregivers Motivating patients Knowledge of patients� medications

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27. The Medical Home

28. The Medical Home Goal: to improve the quality and outcomes of chronic care Method: Interdisciplinary team provides chronic care services to supplement OVs Purchasers pay practices per capita fees to offset the costs of supplemental services, plus shared savings Evaluation: CMS�s Medicare Medical Home Demonstration (MMHD) Other demonstrations of the medical home www.cms.hhs.gov www.pcpcc.net

29. Medicare Medical Home Demo 8 states, 400 practices, 2000 physicians Application to participate Recognition as a medical home (tiers) Enrollment of patients Monthly payments per capita Depends on the practice�s tier, the patient�s risk Shared savings payments (80%) Participation in the evaluation of the MMHD

30. Guided Care �Enhanced�(Tier 3) Medical Homes Provide at least 21 �medical home� services 18 required services 3 of 10 optional services Practice infrastructure Leadership: med. director or practice admin. Multi-purpose electronic health record (EHR) Guided Care nurse (RN) LPN

31. Payments to Tier 3 Medical Homes Encounter-based FFS payments Care management fees ~$197,000 per physician per year Depends on size and morbidity of panel of Medicare beneficiaries with chronic conditions Shared savings 80% of Medicare�s net saving to be shared with participating practices CMS evaluation contractor will calculate the savings

32. MMHD Timeline Selection of implementation/evaluation contractors � by September 30, 2008 Approval by OMB Identification of the 8 states RFPs to practices � by April 2009 Technical assistance � by April 2009 Application and recognition as a medical home � by November 2009 Payments and evaluation � January 2010-December 2012

33. Technical Assistance Guided Care implementation manual On-line course for nurses On-line course for physicians Guidance in selecting EHRs Online practice self-assessment Information by Internet and telephone Learning collaboratives in 8 states Consultation

34. Partner Organizations AMGA MGMA AAFP/TransforMED Institute for Johns Hopkins Nursing ANA / ANCC

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36. Discussion www.GuidedCare.org