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…….

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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