healthcare unbound san diego, ca july 12, 2011patient-centered primary care a foundational component...
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Patient Centered Medical Homes and Accountable Care Organizations
Two Sides of the Same Coin
David K. Nace MD , Medical Director, McKesson Corporation
Co-Chair, Center for eHealth, PCPCC
Healthcare Unbound
San Diego, CA July 12, 2011
Healthcare ReformMoving Toward an Accountable Health Care System
Coverage for All
Payment ReformAlign incentivesPay for Value
Strengthen Primary Care
Health Information Technology
Tools to Rebuild and Restructure Health Care
Patient-Centered Primary CareA Foundational Component of Accountable Care
1st contact care for health that is continuous, comprehensive & coordinated across care continuum
Adoption of innovations such as electronic information systems
Population-based management of chronic illness
Focus on delivering evidence-based medicine & continuous quality improvement
Extended access to care e.g., after hours/weekends, email, other tech media
PCMH
Improving access to primary care has positive resultsPreventive care increases Immunization rates improveER visits & hospitalization decline Health care costs decrease
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Health IT Framework
Accountable Care and PCMHTwo Sides of the Same Coin
PCMH
PCMH
PCMH
PCMHHospitals
Public Health
Community Care TeamCare CoordinatorCase Managers
Behavioral Health SpecialistCommunity Health Workers
Specialists
A Coordinated Health System
PCMH
What is Accountable Care?
Accountable care requires physicians to change how they deliver care and to work with other providers and payors in collaborative ways
Significant care coordination between providers caring for a patient
Ability to collect and share information across care givers and patients
Performance transparency across the system and stakeholders
Shifting to a primary focus on patient health & care outcomes rather than on transactions/intensity of services
Accountable care is a term that is often a proxy for the desired outcome of health reform efforts: high quality care at the best possible cost
Key Elements to Achieve Accountable Care
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Care CoordinationAn Essential Function of Accountable Care
Guide Patients
• Access & follow-up• Right setting, right provider• Comprehensive information
Coordinate providers as a team
• Ensure sharing of information and perspective
• Align efforts toward common care plan
Manage transitions
• Enable seamless & effective care setting transitions
• Support a positive patient experience
Targeted care coordination may involve assigning a care coordinator to specific cases, including face-to-face patient contact
Care coordination using team-based models has been shown to improve health outcomes and/or reduce hospitalizations, readmissions and costs
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Clinical Decision Support & EBMCan work together to improve care delivery…
• Assist clinicians at the point of care by providing the right information at the right point in the workflow to improve health care decisions and reduce errors and/or redundancies.
Clinical Decision Support
Use of standardized clinical processes, protocols, and guidelines to ensure that care processes are uniform, and follow what we know to be best practices, improving care decisions about when and how to treat, or not to treat.
Evidence-based Medicine
…and reduce cost
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Care Management Improving care quality, outcomes, and costs for complex care
Patient engagementTargeted Services Assist in coordination of their careDevelop care planRemoving barriers to care
CM services traditionally offered by payors (tele, web, embedded)Health system and/or provider practices could offer the same type of service (some do today)Many questions remain on where this function will sit in the new care delivery world……
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Care Transition ManagementOptimizes the transition of care from one setting to another
• Few providers monitor readmissions or follow up with discharged patients
• Results in 20% of patients being readmitted within 30 days
Today Limited Care
Transition Mgmt
• Implement discharge processes & specific evidence-based transitions of care programs protocols
• Ensuring that appropriate providers are available and able to perform
• Facilitate support systems for patients
PCMH / ACO Readmission & Transition Mgmt
Medication ManagementKey component to improving cost & quality
Adoption of specific
protocols & technologies
Counseling by pharmacists
1) Improved adherence
2) Less adverse reactions
3) Improved outcomes
Non-adherence to medications is responsible for 33% - 69% of medication-related hospital readmissions, and 20% of discharged patients experience an adverse event that is largely medication related
Pharmacists Role in Connected Care TeamParticipate in medication reconciliation & adherence management strategiesMonitor clinical resultsDetermine therapeutic switchesAddress safety issues
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Prevention & WellnessEven more important under accountable care
Incorporate prevention strategies to support population health & wellnessTarget lifestyle issues and occupational factors that impact the populationPrimary care practice can play central roleHealth systems collaborating with local Govt. and employers to impact population healthLeveraging evidenced-based prevention and wellness strategies
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Performance ManagementUnderstanding & leveraging provider data
Data is a critical asset that must be leveraged− ACOs will need to implement sophisticated data
management capabilities across their providers
Standardized protocols & performance metrics− Accountable care will need data, analytic &
reporting structures to deliver performance results
The promise of analytics…..
PCMHs / ACOs that can leverage claims, lab, EHR & patient satisfaction data will be at forefront of performance
management
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Patient-centric CareThis will be a significant performance requirement
• Surveys for patient self-assessment
Patient activation tools
Online education tools
Coaching techniques
Evaluation of health literacy
Incentives for engagement
Actively engage and empower patients…
…a new way of thinking for providers
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Health Information Technology Enabling Practice Transformation
To support PCMH (practice) and ACO (enterprise) practice transformation, an interconnected HIT network with key capabilities acts to optimize
engagement and coordinate care
HIT as an enabler of Access, Care Coordination, and Care Integration
HIT-Enabled Health Reform“Meaningful Use” - an iterative approach
2009 2011 2013 2015HIT-Enabled Health Reform
Mea
ning
ful U
se C
riter
ia
HITECH Policies Data capture
and share data
Advanced care processes
Improved Outcomes
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Nation-wide regional extension program to assist primary care providers achieving ‘meaningful use” of HIT
A foundational shift in Health Information Technology (HIT) must occur in order to drive widespread adoption of the Patient Centered Medical Home (PCMH) model, and support the Accountable Care Organization (ACO)
- “Better to Best : Value Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations”, March 2011, Health2Resources, Washington, D.C.
What we are now learning……
Anchoring the EHR in the traditional visit based care delivery model limits the potential of the medical home to generate paradigm shifting care delivery transformation and positive outcomes1
1 Zayas-Caban,T., Finkelstein,J., Kotharim, P., .Quinn, M., Nace, D. “Cyberinfrastructure for the Patient Centered Medical Home : Current and Future Landscape” (in press)
The Nature of the Problem
Problems Reported in Adopting PCMH Adoption of EHRs
−Poor cross-system communications and response times−Costly implementations and interfaces −Failure to support role-based access, teamwork, and shared
decision making −Huge challenges in managing medication lists, problem lists,
and care plans across HIT platforms− Inefficiencies caused by non-integrated, “bolt- on”, and silo’d
applications and databases−Failure to meaningfully engage the consumer2,3
2 Bates, DW, Bitton A. The Future Of Health Information Technology In The Patient-Centered Medical Home, Health Affairs, 29, no. 4. 3 Fernandopulle R, Patel N. ―How The Electronic Health Record Did Not Measure Up To The Demands Of Our Medical Home Practice Health Affairs, 29, no. 4 (2010): 622-628
Meaningful UseHIT&E that Promotes Better Care
This is NOT about boxes in doctors offices – it is about fostering true “meaningful use” with HIT
• Centering care around the “patient” not the practice• Involving patients in their own information and care
decisions• Supporting decisions when and where needed • Collecting real-time performance information for
measurement on care processes and outcomes• Promoting innovation and new ways of care delivery
Secure Messaging Telephonic / Cellular (routing, texting, twitter, etc.)Same Day / Convenience Scheduling Access to Team Members Remote MonitoringPHR / EHR Access (Patient-centric Record)Access to Care Plan (Shared)Patient / Family Feedback to Practice (QI)Patient Engagement Tools
Capabilities of HITEnabling Access
Capabilities of HIT Enabling Coordination of Care
Reminders / Outreach Team CoordinationReferral ManagementDiagnostics Results ManagementCare Transitions ManagementHolistic Care Coordination (360 degree)Case / Condition Management Care Plan / Medication AdherenceShared Decision – support Tools
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Patients
Hospitals
Affiliated Physicians
Health Plans
Pharmacies
Partners
Employed Physicians
Internet based networks can deliver immediate value through a patient-centered strategy
Patient centricity is a paradigm shift, that can catalyze structural changes in the delivery system…….
7/20/2011 22
Patient Centricity Critical to Driving Value
SpecialtyProviders
Primary Care Providers
Consumer PHRs
Loca
l Clin
ical
Inte
grat
ion
Reg
iona
lly C
onne
cted
Patient Centric Platform
HospitalsHospital Lab & Radiology Centers
Home Health Services
Community Labs
Nat
iona
lly C
onne
cted
Payers
NHIN
Regional Health Systems
State RHIOs
Patients
Extending from the Practice……. to the Community
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Regional HIE Collaboration Northern California Market
Six Health Organizations Collaborating in the SF Bay Area
• Over 3,000 connected physicians
• Over 1,000,000 connected patients
• More than 150,000 actively connected individuals
• Providers and hospital information exchange
• Reference lab collaboration
• Coordinated care across community
• Interoperability with 5 different vendors (Cerner, GE, NextGen, McKesson, Dynamic Business Solutions)
ABMG
JMH
JMPN
UCSF
HPMG
LabCorp
San Ramon
Referrals
PatientMessaging
Orders
Pre-Registration
Results
ePrescribing
Colleague Messaging
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Regional HIE Collaboration Northern and Central New Jersey
Six Health Systems Collaborating in the Northern and Central New Jersey Market
• Part of a state-wide HIE initiative
• Over 1,400 connected physicians
• Over 510,000 connected patients
• More than 33,000 actively connected patients
• Over 20,000 electronic prescriptions/month
• Over 53,000 clinical documents and lab test results transmitted per month
Clients
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Accountable Care OrganizationsThe overarching structure in which other reforms can thrive
Roanoke, Va
Pilot Activity
Source: Brookings & Dartmouth Institute, 2009
Sources: Delivery System Reform: Developing Accountable Care Organizations, John Bertko, Brookings Institution, May 2009; Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandaries, Devers & Berensen, Oct 2009, Robert Wood Johnson Foundation
4 Key Pillars of Competency Accountable Care OrganizationsI. Consumer Engagement and PCMH
the ability to actively engage patients in their care process, provide patients with access to their pertinent information, and enable a range of personal health management and health information tools.
II. Analyticsthe ability to identify and stratify populations for management, manage cost and quality, address PMPM spend, generate and act upon care gaps, understand and optimize provider performance, and support stakeholder and regulatory reporting.
III. Care Managementthe ability to leverage evidence based decisions in the delivery of care, create efficient and effective utilization management programs, and establish an integrated medical management workflow system for utilization and disease management.
IV. Financial Managementthe ability to leverage analytics to define and support care bundles and identify network / provider efficiency in preparation for undertaking bundled payment and support for additional payment mechanics.
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Infrastructure for Accountability
• PCMA and ACO are “views” of accountable care – a practice view and a system view
• Health information technology has enormous potential to improve primary care, and plays a pivotal role in implementing both the PCMH (micro) and ACO (macro) models
Conclusions
Questions
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