AHRQ and the Medical Home:Building a Blueprint

David Meyers, MDDirector, AHRQ Center for Primary Care

AHRQ Annual ConferenceSeptember, 2010

Disclosures

The speaker has no financial or other conflicts of interest to report

Disclosures

The speaker has no financial or other conflicts of interest to report

(After all, I’m a bureaucrat)

Bureaucrat

bu·reau·crat – 1.an official of a bureaucracy. – 2.an official who works by fixed routine

without exercising intelligent judgment. Or in my son’s words…

I go to a lot of meetings and spend my day reading and writing email.

Session Overview

Introductions and Welcome (5 minutes) An Update on AHRQ’s Activities

in Support of the PCMH (15 min) Perspective: Research Needs (10 min)

– Debbie PeikesSenior Researcher, MPR

Perspective: Implementer Needs (10 min)– Michael Barr

Vice President, ACP Audience Response (40 minutes)

– Where should AHRQ focus future activities in support of the PCMH?

Wrap-up (5 minutes)

Goals

1. Participants will leave with an understanding of AHRQ’s activities in support of the primary care PCMHa) Participants will see how feedback from their colleagues in

2009 has been incorporated into AHRQ’s activities

2. AHRQ will leave with a fuller understanding of the needs of its stakeholdersa) Researchersb) Implementersc) Policy-makersd) American public

AHRQ Mission Statement

To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

What AHRQ does

Generates New Knowledge

The Medical Home

AHRQ believes that the primary care medical home, also referred to as the patient centered medical home (PCMH), advanced primary care, and the healthcare home, is a promising model for transforming the organization and delivery of primary care.

Synthesizes Evidence

Supports Implementation

A home for the PCMH

Center for Primary Care, Prevention, and Clinical Partnerships– Primary Care

PBRNs– Health IT– Prevention and Care Management– Mental Health / Primary Care Integration

Primary Care

AHRQ recognizes that revitalizing

the Nation’s primary care system is foundational to achieving

high-quality, accessible, efficient health care for all Americans.

The Medical Home

A medical home is not simply a place but a model of primary care that delivers care that is: – Patient-Centered– Comprehensive– Coordinated– Accessible, and– Continuously improved through a

systems-based approach to quality and safety

The Medical Home

A medical home is not simply a place but a model of primary care that delivers the care that is: – Patient-Centered– Comprehensive– Coordinated– Accessible, and– Continuously improved through a systems-

based approach to quality and safety

AHRQ believes that Health IT, workforce development, and payment reform are critical to achieving the potential of the medical home.

AHRQ’s Definition of the Medical Home

http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_

AHRQ and the Joint Principles Closely Aligned

Patient-Centered Comprehensive

– Team-based care

Coordinated Accessible Quality and safety Health IT Workforce development Payment reform

Personal physician Physician directed

practice Whole person

orientation Care Coordination

– Health IT

Quality and safety Enhanced access Payment

AAFP, AAP, ACP, AOA

AHRQ PCMH Research

Retrospective Evaluations– Health Partners (Minnesota)– WellMed (Texas)

Mixed Methods Evaluations– Transforming Primary Care Practice

14 2-year awards $600K per study Awarded summer 2010

Establishing a Research Agenda– Co-funded with CWMF and ABIMF– Collaboration of SGIM, STFM, APA– Results published June 2010 in JGIM

Measurement

Developing measures of care coordination in primary care– Care Coordination Measure Atlas

Collaboration of Battelle and Stanford Released this week

– Phase II of measure development 2010-11

Measurement

Developing measures of care coordination in primary care

Planning for development of measure of ‘team-ness’– Multi-partner collaboration – Kick-off meeting held earlier this month

Measurement– Developing measures of care coordination in primary care– Planning for development of measure of ‘team-ness’– Developing a PCMH version of the Consumer Assessment of

Healthcare Providers and Systems (CAHPS) Expected in 2011

Synthesis

Foundational White Papers– Necessary but Not Sufficient: The HITECH

Act’s Potential to Build Medical Homes– Engaging Patients and Families in the

Medical Home– Integrating Mental Health into the Medical

Home

– Developed in collaboration with Mathematica Policy Research and National Commission on Quality Assurance

Synthesis

Foundational White Papers– Necessary but Not Sufficient: The HITECH

Act’s Potential to Build Medical Homes– Engaging Patients and Families in the

Medical Home– Integrating Mental Health into the Medical

Home

– Address Policy and Research Issues

Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes

While the meaningful use of Electronic Health Records (EHRs) helps support some aspects of the PCMH model, policy options available in HITECH and in broader health reform legislation could ensure EHRs are implemented in a way that will support primary care transformation.

Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes

Policy options include:1. Adding explicit functionalities that directly support

the PCMH model to the recently released EHR certification standards and criteria.

2. Adding meaningful use requirements that support the PCMH model for stages 2 and 3 of the EHR Incentive Program.

3. Funding the provision of technical assistance to primary care practices on PCMH transformation alongside the planned assistance on health IT adoption through Regional Extension Centers (RECs) or through a Primary Care Extension Service.

Engaging Patients and Families in the Medical Home

How can policymakers ensure that the PCMH is responsive to and reflective of the goals, preferences, and needs of patients?

By promoting the involvement of patients and families in the medical home at three levels: – in their own care, – In practice-level quality improvement, and – In policy and research

Engaging Patients and Families in the Medical Home

Policy options include:

Requiring patient involvement to qualify a practice as a medical home

Using financial incentives to reward practices for involving patients and families

Supporting practices with technical assistance and tools

Ensuring Health IT is patient-focused Incorporating patient input in the design,

implementation, and evaluation of medical home pilot projects

Conducting additional research

Integrating Mental Health into the Medical Home

Normalize MH in mainstream medical practice – truly adopt a whole person approach to care.

Integrate reimbursement for the time and resources needed to provide MH treatment in the PCMH.

Develop performance measures to encourage adoption of integration while providing a source for ongoing feedback and improvement opportunities.

Two Additional Reports

Building Value: The Role of PCMHs and ACOs in Care Coordination

Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care

Synthesis

Database of published literature on the medical home– Over 500 citations– Searchable by PCMH domain, policy

relevance, and outcomes– Includes a section on foundational

documents and articles

Implementation

Synthesis Planned white papers for 2011:

– Analysis of PCMH outcomes– Exploration of PCMH within the larger health care system– With potential for additional topics

Upcoming series of briefs on the status of primary care in the US– Includes new analysis of the primary care workforce

Toolkit on integrating the CCM in safety net setting– Visit: http://www.ahrq.gov/populations/businessstrategies/– Companion toolkit on utilizing practice coaching

Visit: http://www.ahrq.gov/populations/businessstrategies/coachmanl.htm

– Currently conducting field evaluation

National learning collaborative around the use of practice facilitators and practice coaching– Launching fall 2010

Implementation

Building a PCMH Information Model– Describe the PCMH in terms of the information

flows and interactions between and among patients/consumers and other PCMH stakeholders

– Develop new ‘functional use cases’– Examine current standards and existing ‘technical

use cases’ in relation to the PCMH– Identify gaps

– Contract awarded to Westat– Began Summer 2010

Opportunities

2010 Affordable Care Act:– Section 3502: Establishing community

health teams to support the patient-centered medical home

– Section 5405: Primary Care Extension Program

Both sections authorized without the appropriation of funds

Putting it All Together

Research Measurement Evidence Synthesis Evidence-informed Policy Options Implementation

Dissemination

PCMH.AHRQ.Gov

PCMH.AHRQ.Gov

Targeted towards meeting the needs of Policy Makers and Researchers

Includes:– AHRQ definition of the medical home– Searchable article database– Foundational white papers

Health IT Patient and Family Engagement Mental Health Integration And additional reports

PCMH.AHRQ.Gov

Targeted towards meeting the needs of Policy Makers and Researchers

Includes:– AHRQ definition of the medical home– Searchable article database– Foundational white papers

Will continue to grow and expand

PCMH.AHRQ.Gov

Targeted towards meeting the needs of Policy Makers and Researchers

Includes:– AHRQ definition of the medical home– Searchable article database– Foundational white papers

Will continue to grow and expand

Please visit and help us spread the word

Federal Collaboration

AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care

Federal Collaboration

AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care

In response, AHRQ convened a Federal Collaborative on the PCMH– Share information so that participants have

a common understanding of PCMH– Foster collaborations and share expertise

Thank You

One minute for clarifying questions… Research Needs and the Needs of

Researchers

– Remarks from Debbie Peikes, Ph.D. Senior Researcher at Mathematica Policy

Research Visiting Lecturer at Princeton University

The Patient-Centered Medical Home: Research Needs and the Needs of Researchers

September 27, 2010

AHRQ Annual Conference

Bethesda, MD

Debbie Peikes, Ph.D.

We Need Good Evaluations

Payers/insurers: Will the PCMH reduce costs enough to cover the payments to providers and in-kind supports?

Practices: Transformation requires staffing, IT changes, time, and $. Will these translate into more satisfaction, $?

Patients: Will experience and outcomes improve? Will premiums fall?

Vendors: Will this movement exist in 5 years?

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The PCMH Model is Promising. . . but Risky

Risks:

Model isn’t actually implemented fully

Model is implemented, but does not work– Increases costs– Decreases satisfaction of patients– Decreases provider satisfaction– Decreases quality

Simply proceeding without evidence may divert resources from other primary care transformations that would work

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What Can an Evaluation Deliver?

Document whether the PCMH model was implemented

Identify barriers and facilitators to being a medical home

Assess effectiveness to justify investment

Measure performance to reward providers differentially

Guide replication of successful features

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How Do Practices Evolve into Medical Homes?

Efforts needed to reach MH criteria (time, internal and external resources, $)

Limits, potential of health IT

Ease of changing staffing and workflows

Resources required from outside the practice

Best practices and models– For patient outreach, recruitment, and

engagement– For coordination– For chronic care, etc.

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What Is the Impact of the PCMH? Disease-specific and population-based quality of care

measures– Process: Evidence-based care (e.g., foot exams

for patients with diabetes)– Outcomes: Ambulatory-care sensitive

complications– Coordination of care (harder to measure)– Patient experience

Provider experience– If providers are worse off, they won’t want to do this

Service use and cost– If this isn’t cost neutral or cheaper, payers won’t

play

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Current Research Evidence is Weak

Well designed studies are not testing the full medical home (e.g., Guided Care, GRACE), or do so in a closed system (Group Health), or don’t have access to cost data (NDP)

Many studies are poorly designed, or do not report methods (e.g., North Carolina)

Many planned studies are too short, have not represented the counterfactual, do not address clustering, and are underpowered

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Research Needs-2

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Research Needs1. Standardized measures of different medical home models to test variants

2. Fair comparison groups-similar before the intervention At the practice level At the patient level Consider random assignment, staggered rollouts

3. Information on best claims-based approaches to attribute patients to their practices

4. Adequate follow-up Need time to allow transformation to happen Most evaluations are using only 1.5–2 years

5. Statistical techniques that account for clustering at the practice level Not doing so will give false positives

6. Large sample sizes We may erroneously find no effect because practices don’t have enough time to change or there

isn’t enough sample to detect change Costs vary so much it is difficult to separate intervention effects from random noise (this affects

P4P too!)

7. Data repositories and guidelines for cross-walking all payer claims data

8. Well defined intermediate and final outcome measures that are comparable across studies

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Your Thoughts?

dpeikes@mathematica-mpr.com

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Feedback from the Front Lines

Remarks from Michael Barr

Feedback from the Front Lines

AHRQ Annual MeetingSeptember 2010

Michael S. Barr, MD, MBA, FACPSenior Vice President

Division of Medical Practice, Professionalism & Quality202-261-4531

mbarr@acponline.org

Disclosure of Conflicts of Interest:

Grant funding from Pfizer and UnitedHealthGroup to support program development (ACP Medical Home Builder)

Quality improvement programs sponsored by pharmaceutical companies as part of ACPNet & ACP Closing the Gap

"I put a dollar in a change machine. Nothing changed." — George Carlin

Anecdotal Reactions

Some

What ^ Physicians Hear…Patient-Centered Medical Home

Health Care HomePerson-Centered Health Care Home

Meaningful UseCertified EHR Technology

Complete EHRsEHR Modules

Accountable Care Act (PPACA, ACA)Maintenance of Certification

Physician Quality Reporting Initiative – PQRIHITECK

E-prescribing Incentive Program

Drawing by: M.C. Escher

What ^ Physicians See…Some

What ^ Physicians Say…• Honestly, I have given up on all my professional organizations -

they simply cannot or will not understand the point of view of the solo practitioner.

• Haven't we given up enough of our autonomy? Aren't enough non-physicians in control of our destiny as it is?

• I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession.

• …the complex requirements of "meaningful use" mainly serve the EHR companies (who, not surprisingly, had a hand in developing the rule).

Some

How ^ Physicians Feel…Some

Physicians Need…

Listening Session

We invite members of the audience to share their observations and recommendations with AHRQ– Our primary goal is to learn from you what

you see as the role for AHRQ moving forward