Building the Patient-Centered Medical Home: Leveraging High-Impact Processes for Care Improvement

1. A quick review of the IHI learning lab

2. Moving into the Medical Home

3. Building the PCMH From the Ground Up

4. Using the Model to Get Broad Outcome Improvement • Build the proper structure • Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of: • Improve the patient experience (satisfaction) • Improve the health of the population • Control or reduce cost • Then measure the outcomes

5. 7 High Leverage Processes • Identification and management of depression • Management of care transitions • Care coordination • Team-based care • Identification and management of socially frail/ isolated individuals • Pharmacologic management including optimizing medication and dealing with adherence issues • Enhancement of the therapeutic environment

7. 1. Depression • Why it’s high leverage • Very high prevalence • Under diagnosed • Major gaps in care • Depressed individuals have more somatic complaints • Chronic illness can produce depression • Depression as a comorbidity roughly doubles the cost of the chronic illness

8. Depression • Using Technology • Identify high risk patients (multiple chronic illnesses, multiple medications, unemployed, on disability…) • Screening built into visits at regular intervals (e.g. PHQ2) • Recall and tracking systems • Medication adherence tracking • Other resources • Community resources • On site integrated behavioral health (e.g. counselors, CNS) • Liaison Psychiatrists and Psychologists

9. 2. Care Transitions • Why it’s high leverage • High risk situation for both quality and cost outcomes • Patients and families experience considerable anxiety and frustration at care transitions • Improving care transitions reduces the incidence of hospitalizations and rehospitalizations

10. Care Transitions • Using Technology • On demand medical records access • Hospital portal • ED and hospitalist access to PCP medical record • Automated HIE • All ED notes, H & P’s, consults, op reports, labs, and imaging reports flow to EMR

11. 3. Imbedded Care Coordination and Case Management • Why it’s high leverage • Community care of North Carolina, Geisinger Health System, Kaiser, Group Health of Puget Sound, and Voice of Detroit Initiative have all reported positive outcomes using imbedded care coordinators • Care coordinators need to be part of the care team with a well defined specific role • Remote third part care coordination and case management has been shown to not work as well

12. Care Coordination • Using Technology • Patient registries embedded in the EHR able to identify specific populations • With particular diagnoses • With gaps in care • Who are overdue for services • Who are not at goal • With high illness burden • With limited social supports • Measure overall practice or physician performance • Benchmarking

15. 4. Team Based Care • Why it’s high leverage • MDs cannot provide all the care in the patient centered medical home model • Consistent with the Chronic Care Model • Improved quality and cost outcomes with team based care (Kaiser, Geisinger, Virginia Mason, CareOregon…)

16. Team Based Care • Key processes • Redefine roles and responsibilities including integrating BH, SW… • The work is done by more people but needs to be coordinated • Internal communication gets more complex • Reframe patient expectations (this can be part of the PCMH) discussion • Technology support • Internal messaging IMs, Texting… • Patient Portals • Shared care plans (ideally web based that can be accessed by the entire care team) • As well as what has become the floor but needs some refinishing CDSS, registries, and tracking systems

17. 5. Socially Frail Individual • Definition: combination of social isolation and low self esteem • Why it’s a high leverage process • Four times the cost of matched populations • Amenable to low cost interventions (brief intervention with a counselor significantly improves outcomes) • Support groups, case management, plug in to local resources, pets… • Risk equivalent to smoking a pack of cigarettes per day

18. How to identify the socially frail individual? • Low self esteem- • Question 6 on the PHQ9 are you feeling bad about yourself or that you are a failure or that you let yourself or your family down. • Lubben Social Network Scale – 6 • Family • How many relatives do you here from at least once a month? • How many relatives do you feel at ease with that you can talk about private matters? • How many relatives do you feel close to such that you could call on them for help? • Friendships • How many of your do you see or hear from at least once a month? • How many friends do you feel at ease with that you can talk about private matters? • How many friends do you feel close to such that you could call on them for help?

20. 6. Medication Management • Why it’s high leverage • High prevalence of polypharmacy in patients with chronic illness • Increased adverse drug events, drug-drug interactions • Issues of non-adherence, affordability, and patient confusion • Studies have shown decreased benefit when patients are taking more than four medication • Significant morbidity, mortality and cost associated with medication mismanagement

21. Medication Management • Key functions • Identify patients at risk due to polypharmacy and non-adherence • Manage out of pocket costs • Address various contributors to non-adherence • Medication reconciliation • Technology infrastructure • EHR • drug-drug and drug-condition programs • Formulary management programs • Filled prescription information • Portal • HIE • Brainstorming ideas: • Flash drives, medication reminder apps, blister packing

22. 7. Enhancing the Therapeutic Environment • Why it’s a high leverage process. • Patients highly value the relationship with their provider • Continuity and the duration of the relationship correlate with positive outcomes • Patients want a care team who take the time to listen to them and to know them as individuals • The relationship often helps with patient activation • Key functions • Continuity • Tracking patient preferences • Access (visits, phone, e-mail…) • Outreach • Responsiveness • Caring relationship

23. Enhancing the Therapeutic Environment • Technologic support • Secure messaging • Patient portal • Web-sites • Recall systems • Patient interaction with EHR • Use the EHR to track specific patient details

25. Summary • Superior clinical outcomes require investment in sustainable structures and processes • Medical homes can help achieve the goals of improving the patient experience, reducing costs, and improving population health • Focusing on highly leveraged processes and using technology are essential • Using technology thoughtfully is equally important