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This presentation outlines the integrated system developed by Intermountain Medical Group for personalizing patient care. It details two distinct models: the Distributed Model, focusing on personalized primary care, and the Intensive Model, designed for high-risk patients. Highlighting a team-based approach, the initiative involves various healthcare professionals, including primary care clinicians and mental health providers. The presentation also shares clinical quality outcomes and patient satisfaction metrics derived from the implementation of this personalized care system from 2010 to 2014.
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Building an Integrated System for Personalizing Care Tim Johnson, MD Spring, 2014
1,056 physicians • 342 primary care • 491 secondary care • 86 hospitalists • 17 radiologists • 120 urgent care • 265 advanced practice clinicians • 81 primary care clinics Intermountain Medical Group
Dual Model for the Medical Home • Distributed Model • Intensive Model
Distributed Model: Personalized Primary Care • Intermountain Medical Group and SelectHealth • Modeled on 2011 PCMH NCQA Standards • Team members • Primary Care Clinician • RN Care Manager • MA Health Advocate(s) • Advanced Practice Clinicians • Doctor of Pharmacy • Mental Health Integration
Personalized Primary Care • Implementation 2010 - 2014 • 64 adult primary care clinics • 17 pediatric clinics • 345 physicians and advance practice clinicians • ~100 care managers and health advocates • Hybrid model: central and region leadership • Level 2 and level 3 within 2-3 years
Personalized Primary Care: Results Clinical Quality Allowed Per Member Per Month • Intermountain diabetes bundle: • HgbA1c < 8% • LDL < 100 • BP < 140/90 • Annual nephropathy screen • Eye exam every 2 years 35% 20% Total Cost Trend* Patient Satisfaction Years after Implementation *Preliminary results, risk-adjusted and normalized for contractual payment differences
Intensive Model: Personalized Care Clinic • An outpatient clinic that provides intensive medical, behavioral, and social management for Intermountain’s high-risk patients • Patients in the top 5-10% of costs for 2 of the last 3 years
Personalized Care Clinic: The Team • Internal Medicine Physician • Palliative Care Physician (0.2) • RN Care Manager • Psychiatry APRN • LCSW • Pharmacist • 2 Medical Assistants • PSR • Clinic Manager • Assistant Region Operations Officer • Region Medical Director
Personalized Care Clinic: Process of care • Acts like a primary care office with more resources to coordinate care, address mental health conditions, and manage complex medication issues • Ensure patients receive care in appropriate setting – focus on acute care utilization • Coordinate and collaborate with all of the patient’s specialists • Committed to eliminating all avoidable health care emergencies
