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Group Health’s Medical Home JourneyInvestments and Returns for ExcellenceAlicia Eng, Interim Vice President, Primary Care Services
The National Medical Home Summit WestSeptember 21, 2011
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Who we are
•Integrated health delivery system•Founded in 1946•Consumer governed, non-profit•Membership: 661,500 Staff: 9,365•Revenues (2009): $3 billion
•Group Health Research Institute•34 investigators•235 active grants, $39 million (2009)
•Multispecialty Group Practice• 26 primary care medical centers• 6 specialty units, 1 maternity hospital• 985 physicians
•Contracted network• > 9,000 practitioners, 39 hospitals
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Group Health
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Medical Home Design Principles
✔✔✔✔
✔ The relationship between the clinician & patient is at our core. The entire delivery system will reorient to promote & sustain.
The primary care clinician will be a leader of the clinical team, responsible for coordination of services, and together with patients will create collaborative care plans.
Care will be proactive and comprehensive. Patients will be actively informed and encouraged to participate.
Access will be centered on patients needs, be available by various modes, and maximize the use of technology.
Our clinical and business systems are aligned to achieve the most efficient, satisfying and effective experiences.
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Medical Home Investments
Panel size
1,8002,300PCMH design:
Clinical teams Desktop time E-technology
Appointments
20 min.
30 min.
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Medical Home 1 & 2 Year Pilot Outcomes
Group Health Research Institute
Year 1
Year 2
QUALITY (HEDIS)Year 1: Rate of rise, 2x that of control clinics
Year 2: Rate of rise continued to be 20 – 30% greater in 3 of 4 composites
PATIENT/STAFF SATISFACTIONYear 1: Patient satisfaction – 5% increase in patient activation/goal setting;
Practitioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalization
Year 2: Scores continued to improve at Medical Home; controls were slightly worse
ED/UC UTILIZATIONYear 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but
longer in-person visits
Year 2: Significant changes persisted
COST Year 1: Cost is neutral
Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM)
Source: Health Affairs 29:5 May 2010
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Reid RJ et al, Health Affairs 2010;29(5):835-43Larson EB et al, JAMA 2010; 306(16):1644-45 Reid RJ et al, Am J Manag Care 2009;15(9):e71-87
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Mapping the Value Stream
OutreachWorkcell
Includes:1. ED/UC outreach2. Hospital/SNF discharge outreach3. Complex Case Management outreach4. Disease Management outreach5. Chronic Care outreach (Doc & Coding)6. HEDIS outreach7. Lipid Mgmt outreach8. TRIP outreach, Pharmacy outreach
OutreachCell Development- Who/Roles- Work Rules- Virtual or Physical - Standard Work for Outreach- Outreach Prioritization Criteria
Primary Care Future State Map August 19 – 21, 2008Medical Home Model
Other Demand
Other Demand
Other Demand
Appoint Patient
Provide Care Follow Up
(Increase Use of) Virtual
Medicine(Call Management & Secure Messaging)
Patient
Strategies & Tools for
Increasing Use of Virtual Medicine
PREREQPanel Size =
1800 rawStandard Work for Moving Panel
- Includes Strategies for Hard to Recruit
clinics
Define M-F Template Variation
Consistent pre-visit prep work (MD and flowstaff)
Prep for Visit
Determine Medical Home Applicability to
Pediatrics- Panel, Visit levels, Peds RNs
Standard Work for
Managers/Leaders
PREREQDefine Facility Assessment
Needs/Strategy
Standard Work for Huddles & Pre-visit Prep
- Team Huddles (everyone attends)- Dyad Huddles
PREREQVisit Length =
30 minutes
-More holistic care/opportunistic care
PREREQ1:1 MD/Flow Staffing (consistent each day
if possible)PREREQ
Co-Location of Team Members
Standard Work for Chronic
Disease Mgmt- Meet regulatory requirements, build reporting
Consistent AVS usage
Select Standard
Tools/AVS Content
Design Heijunka
Format & RulesHeijunka Box to Level Work
XOXOConsistent
Use of Visual Systems
LEGEND PREREQ Prerequisite for individual clinic before going live
Improvement work
Medical Home element to be
spread
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Spreading the medical home
Virtual Medicine
Disease Management
Visit Preparation
Patient Outreach
1. Staged spread of practice change modules
Team Huddles Standard Mgmt Practices
Enhanced Staffing Model Value-based MD Payment Model
2. Supported by management & staffing changes
Standardization & Spread using LEAN methods
Acute and Planned Visit Access
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Medical Home 1 & 2 Year Pilot Outcomes
Group Health Research Institute
Year 1
Year 2
QUALITY (HEDIS)Year 1: Rate of rise, 2x that of control clinicsYear 2: Rate of rise continued to be 20 – 30% greater in 3 of 4 composites
PATIENT/STAFF SATISFACTIONYear 1: Patient satisfaction – 5% increase in patient activation/goal setting; Practitioners - *substantially less burn-out with significantly reduced emotional exhaustion & depersonalizationYear 2: Scores continued to improve at Medical Home; controls were slightly worse
ED/UC UTILIZATIONYear 1: 29% fewer ER visits, 11% fewer preventable hospitalizations, 6% fewer but longer in-person visitsYear 2: Significant changes persisted
COST Year 1: Cost is neutral Year 2: Overall patient care costs lower at Medical Home (~$10 PMPM)
Source: Health Affairs 29:5 May 2010
2010 performance continues to hold for:
•Quality
•Patient/Staff Satisfaction
•ED/UC and Hospital Utilization
•Cost
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•Building on the Foundation
-The Patient Centered Medical Home
•Accountable Care
- Provider Partnerships
Opportunities for Further Investments
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Building on the Foundation
• The Patient Centered Medical Home
– Full Capitation
– Integrated group practice – Primary Care and Specialty
– Manage a full continuum of care in an integrated, local delivery system
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Value Created from Integration
Entry
Scale‐up • Add wrap‐around services: e.g. Hospitalists
• Add specialties that scale warrants (e.g. Pulm, Oncology, Occ
Med)
Observation • Add observation unit: 24/7 urgent care coverage
• Enter with Primary Care Medical Home minimum scale
‐
2 – 4 provider is minimum scale
‐
Waived testing, “Rx‐lite”
(e.g., sampling, mail order, ADM)
Efficient scale• Add remaining specialties as scale warrants,
e.g. Allergy, neurosurgery, infectious disease
• Add additional ancillary (Rx & Lab) & after hrs urgent care
• Add specialties as scale permits:
‐
Smaller scale: e.g. OB‐GYN, Pediatrics
‐
Mid‐scale: e.g. Anesthesiology, General Surgery
‐
Larger scale: e.g. GI, Neurology
MinimumEnrollm
ent
120K+ enrollees
Cumulative PM
PM value
$50M ‐
$200M PMPM value
(depending on LOB)
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Accountable Care
• Provider Partnerships
– Groups of practices come together around a population
– Focus on the patient and care models to improve care and lower costs
– Establish specific spending levels and shared savings under fee-for-service or increasing degrees of capitation
– Select partners with shared values and principles
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• Increase PC presence in the market through partnerships and acquisition
– 1% annual impact on Hospital Inpatient Utilization over 5 years
– 0.5% annual impact on Hospital Outpatient Utilization over 5 years
• Build a Specialty Group
– Incremental 25-40 Specialty FTEs across target service lines
– Shift $20-30M ongoing operating external delivery system spending to internal
• Joint clinical programs and integration utilizing care management and other features of patient support:
– 2% annual impact on Hospital Inpatient utilization over 5 years
– 1% annual impact on Hospital Outpatient utilization over 5 years
• $20 million in savings across Integrated system by year 5
– Lower premium and costs of care
– Distribution in shared savings to partner provider groups and hospital to account for decrease in claims revenue
Network Design & Clinical Integration in Spokane
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Keys to Success
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Contact Information
Alicia Eng, Interim Vice President of Primary Care Services
Group Health Cooperative, Seattle WA
(206) 448-7323