HIV and Primary Care Transformation: RWCA and the PCMH

Steve Bromer, MD

Department of Family and Community Medicine

UCSF

Goals Why does the US healthcare system need the

PCMH? Why should RWCA clinics transform into

PCMHs? What is the PCMH model and how close are

RWCA clinics to it?

ARS: What role do you play in your clinic?

Provider (Physician or Mid-level) Medical Assistant Front Office Administrator RN Social Worker Pharmacist Other

ARS: My practice setting

Primary Care Practice with HIV Care referred out

Primary care practice with integrated HIV program

HIV Specialty Practice with integrated primary care

HIV Specialty Practice with Primary Care referred out

ARS: Choose the reason

A. To learn more about the Patient Centered Medical Home (PCMH) as a way to transform our practice

B. To learn more about the details of becoming accredited/recognized as a PCMH

C. My boss made me come and Baltimore is a cool city

D. To learn about how concepts from the PCMH apply to multiply diagnosed populations

ARS: Choose the statement you agree with most:

HIV patients need excellent HIV specialty care and primary care is not as important for good outcomes

HIV patients need excellent primary care and the HIV specialty care is not as important for good outcomes

Both HIV Specialty care and primary care are important for good outcomes

With today’s medications, HIV patients will do well regardless of the quality of their healthcare

Mortality Amenable to Health Care

7681

88 84 89 8999 97

8897

109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

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150

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Austra

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1997/98 2002/03Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.

Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.

Abundant research evidence indicates that health systems and regions with a strong foundation of primary care have:

Better population health outcomes Better quality of care More preventive care Lower costs More equitable care and mitigation of health

disparities

Primary Care Strength and Premature Mortality in 18 OECD Countries

*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.

Source: Macinko et al, Health Serv Res 2003; 38:831-65.

Year

High PC Countries*

Low PC Countries*

10000

PYLL

1970 1980 1990 2000

0

5000

Source: Baicker & Chandra, Health Affairs, April 7, 2004

Source: Baicker & Chandra, Health Affairs, April 7, 2004

first ContactComprehensiveContinuityCoordination

A Functional Definition of Primary Care:Barbara Starfield Framework

But the Primary Care Foundationin the US is Crumbling Plummeting numbers of

new physicians entering primary care and burnout among PCPs

Growing problems of access to primary care and “medical homelessness”

Dysfunctional systems that are not delivering the goods in primary care

ARS: Approximately what percentage of adults report difficulty getting a prompt appointment, phone advice, or night/weekend care without going to the ER? 10% 25% 50% 75% 90%

ARS: What is the average time before patients are interrupted when making initial statements to their primary care physician?

2 seconds 23 seconds 58 seconds 98 seconds 120 seconds

ARS: What percentage of patients leave the office visit without understanding what their physician said?

10% 25% 50% 75% 90%

73% of adults surveyed reported difficulty getting a prompt appointment, phone advice, or night/weekend care without going to the ER. Public views on of US health system organization, Commonwealth Fund, 2008

23 seconds: Average time before patients were interrupted when making initial statement of their problem to their primary care physician. Marvel et al. JAMA 1999;281:283

50% of patients leave the office visit without understanding what their physician said. Schillinger et al. Arch Intern Med 2003;163:83

20

Poor clinician/patient relationships

ARS: What percentage of people in the US with HTN are poorly controlled?

10% 25% 50% 75% 90%

Inconsistent Quality• What percent of people in the US have poorly controlled

Hypertension? Diabetes? 25%, 50%, 75%?? Cholesterol?

50% of people with hypertension, 80% of people with high cholesterol, 43% of people with diabetes are poorly controlled.

Egan et al. JAMA 2010; 303(20):2043-2050, Ford, Internat’l J Cardiol 2010;140:226, Cheung et al. Am J Med 2009;122:443

The problem: panel sizes too large for primary care physicians to manage alone A primary care physician with an panel of 2500

average patients will spend 7.4 hours per day doing recommended preventive care. Yarnall et al. Am J Public Health 2003;93:635

A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care. Ostbye et al. Annals of Fam Med 2005;3:209

23

Average panel size in the US is 2300 patients Alexander et al. J Gen Intern Med 2005; 20:1079-83.

Recognition That Reform and Revitalization of Primary Care is Essential for ACA and Health Care Reform to Achieve Its Goals

The President Wants More and Stronger Primary Care

“It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors

Senator Orrin HatchSenate Finance Committee RoundtableReforming America’s Health Care Delivery System April 21, 2009

“The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?”

Randy MacDonald, Sr VP House Ways and Means Hearing April 29, 2009

“I will start with the very last question asked by the committee--what is the single most important thing to fix in healthcare? Primary care. Strengthen primary care -- transform it and pay differently using a model like the Patient Centered Medical Home.”

Congressman: “And the second issue?”

“Well, if you don't fix the first issue and do not have a foundation of powerful primary care then you can do nothing else. You have to fix primary care before you can even begin to address a second issue.”

A 20th Primary Care Model Will Not Meet the Demands of 21st Century!

Ryan White: an Unintentional Home Builder “An unintended consequence…. of the RW Care

Act has been the establishment of the comprehensive delivery of multiple services for patients with a complex disease….medical homes for the HIV-infected person…..”

“The act created in his (Ryan White’s) memory, unintentionally created medical homes that are the best examples of how all of us should receive primary care.”

Saag, M. The AIDS Reader, April 24, 2009

Quality: Cervical Cancer

Screening: 60% Oral Health Exam: 36% ARV regimens with no

contraindications: 85.6%

Workforce The Looming Crisis in HIV Care: Who Will Provide the Care?

“In a survey conducted by HIVMA and the Forum for Collaborative HIV Research, a majority of Ryan White Part C-funded programs reported increasing caseloads and serious challenges recruiting and retaining HIV clinicians.

Reimbursement and a lack of qualified providers were the top two barriers cited.”

HIV Medicine Association, 2010

ARSWorkforce: How long have you worked in the HIV/AIDS field?

1. This is my first year

2. 1-5 years

3. 5-10 years

4. 10-15 years

5. 15-20 years

6. More than 20 years

Funding:

HIV Medical Homes Resource Center

Click icon to add picture

Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623

Engagement in HIV Care

Will a 20th Century Model of HIV CareMeet the Demands of the 21st Century Epidemic?

Joint Principles of the Patient Centered Medical Home February 2007

American Academy of Family Physicians American Academy of Pediatrics American College of Physicians

American Osteopathic Association

Transforming the Delivery of Primary Care:The Patient Centered Medical Home

Ongoing Relationship with provider for first-contact, continuous, and comprehensive care;

Health Care Team that collectively cares for the patient;

Whole-person Orientation, including acute, chronic, preventive, and end-of-life care;

Coordinated Care across all elements of the health care system and the patient’s community;

Transforming the Delivery of Primary Care:The Patient Centered Medical Home

Quality and Safety through evidence-based medicine and clinical decision-support tools, information technology, registries, and continuous quality improvement;

Enhanced Access, achieved through such systems as open scheduling, expanded hours, and new options for communication between patients, their physician, and practice staff; and

Payment Reform to reflect the added value that a PCMH provides to patients.

HIV Medical Homes Resource Center

Continuous

First Contact

Comprehensive

Coordinated

Delivery System DesignClinical IS/HITDecision SupportSelf-ManagementCommunity ResourcesProactive TeamsActivated Patients

PatientCentered Medical

Home

Evidence on Value of New Primary Care Models: Case Study of Group Health Cooperative of Puget Sound

Patient Centered Medical Home model piloted at one site in 2007

Avg PCP panel size reduced from 2327 to 1800 Longer face-to-face visits and scheduled time

for phone and email encounters Increased team staffing and teamwork HIT Panel management

Group Health PCMH Pilot:Controlled Evaluation 12 Month Outcomes

Improved continuity of care Better patient experiences (6 of 7 measures) Better composite quality of care score Reductions in ED visits and Ambulatory Care

Sensitive Hospitalizations No difference in total costs at year 1 (lower total

costs by year 2)

Source: R Reid et al. Am J Managed Care 2009;15:e71

Group Health PCMH Pilot:Effect on Clinic Staff

Control Sites PCMH Site0%

5%

10%

15%

20%

25%

30%

35%

40%

34.5%

30.0%

33.3%

9.7%

Baseline

12 Months

Percent with High Level Emotional

Exhaustion

p=.02

Change Concepts for the PCMH

Engaged Leadership Quality Improvement Strategy Empanelment Continuous and Team-based Healing Relationship Organized, Evidence-Based Care Patient-Centered Interactions Enhanced Access Care Coordination

Wagner, EH et al, Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes; February, 2012

The Building Blocks of High-Performing Primary Care: lessons from the field

23 high-performing practices Intensive visits to 7 West Coast practices Discussions with and observations of

clinicians, RNs, MAs, front desk, leaders High-performing practices look about the

same, with variation in the details 10 building blocks -- the foundation of these

practices

Willard R, Bodenheimer T: CHCF April 2012

Building Blocks of High-Performing Primary Care:Share-the-CareTM Model

Change Concepts Building Blocks NCQA Recognition

Engaged Leadership Data for Improvement Enhance Access/Continuity

Quality Improvement Strategy

Empanelment, Panel size management

Identify/Manage Patient Populations

Empanelment Team-based Care Plan/Manage Care

Continuous and Team-based Healing Relationships

Population Management Provide Self-Care Support/Community Resources

Organized Evidence-based Care

Continuity of Care Track/Coordinate Care

Patient-Centered Interaction Prompt Access to Care Measure/Improve Performance

Enhanced Access Expanded Access Template

Care Coordination Mission with objectives and goals

Care coordination with Medical Neighborhood

Trained Leaders

HIV Medical Homes Resource Center

DATA/Quality Improvement Strategy

Change Concepts

Building Blocks

?Ryan White

Formal QI processDefined metricsOptimized HIT

Robust data collectionReporting systems to share data Strategic decisions about metrics

Are we Data Driven organizations?Do we use real-time data on important clinical/operational data to guide day-to-day actions?

Grant requirement to have CQI, robust metrics, early adopter of registry, variable HIT capacity

HIV Medical Homes Resource Center

Empanelment

Change Concepts

Building Blocks?

Ryan WhitePrioritizes patients seeing own PCP Clear denominator at panel level

Empanelment not specific grant requirement, often happens because of structure of practice

Is empanelment a deliberate process where we can use provider panels for quality data , proactive care and to actively manage supply and demand?

Assign all patients to provider panelBalance supply and demandUse panel data to manage population

HIV Medical Homes Resource Center

Team-Based Care

Change Concepts

Building Blocks?

Ryan White

Patients are connected to a Care TeamRoles/tasks defined

Culture shift to share-the-care. Flexible, functional teams, with clearly defined roles

Multi-disciplinary Teams are central to RWCA

Are our teams organized around getting the work done with an explicit vision and clear principles? With defined workflows, skills training and ground rules?

Team-based Care

Why does team-based care matter? Align roles to meet

population needs

Build capacity to make timely access possible

Non-clinician team-members contribute to continuous healing relationship

Foundation for the Template of the future

4. Team-based Care

Traditional Methods of Managing Work Flow

Provider

Chronic Disease

Monitoring

Preventive Med

Intervention

Mental Health Provider

Referral to Specialist

after Assessment

Medication Refill

New Acute Complaint

Certified Medical

Assistant

Case Manager

Test Results

HealthcareSupport Team

Team-based care

• Culture shift: share the care

Stable teamlets

• Co-location

Staffing ratios

Standing orders/protocols

• Defined workflows and roles – workflow mapping

• Training, skills checks, and cross training

• Ground rules

• Communication – healthy huddles, terrific team meetings and constant conversation

Team-based care: stable teamlets

Patientpanel

1 team, 3 teamlets

Clinician/MAteamlet

Patientpanel

Clinician/MAteamlet

Patientpanel

Clinician/MAteamlet

Health coach, behavioral health professional, social worker, RN, pharmacist, panel manager, complex care manager

HIV Medical Homes Resource Center

Prompt Access to Care

Change Concepts

Building Blocks?

Ryan White

24/7 access to care team, patient-centered scheduling options, address barriers to access

Balance supply and demand, open access, multiple channels of access

Do we have a patient-centered approach to access?

After hours coverage, +/- use of advanced access tools

http://www.careinnovations.org/knowledge-center/knowledge-centerwest-county-health-center-video/

HIV Medical Homes Resource Center

Population Management/Panel Management

Change Concepts

Building Blocks

?Ryan White

Plan care according to need, manage high-risk patients, point-of-care reminders

Robust population management, Self-management, Complex Case management, planned visits

Case Management key feature of RWCA, client level data, self-management support

Are we able to focus at the population level and proactively assign resources where needed? Is data used in day-to-day care?

HIV Medical Homes Resource Center

Care Coordination

Change Concepts

Building Blocks Ryan White

Link patient with community resources, referral tracking, coordination of specialty care

Management of care transitions, behavioral health services, communication of results

Comprehensive model of care, often under one-roof, expectation that transitions are tracked

?How good are we at managing the care that happens outside of our four walls?

HIV Medical Homes Resource Center

Conscious Trained Leadership/Values and Mission Statement

HIV Infecte

d

HIV Diagnose

d

Linke

d to HIV Care

Retained in

HIV Care

On ART

Suppresse

d Viral L

oad0

102030405060708090

100

Series 3Series 2Series 1

Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2, 2011/60(47);1618-1623

Engagement in HIV Care

=Access =Care Co-ordination =Population Management

A

P

A

AA

A

C

C

CC

PP

P

HIV Medical Homes Resource Center

Summary

Both Primary Care and the RWCA are at a crossroad

PCMH is one model of transformation RWCA clinics have many components of PCMH There is much to learn from PCMH model and

high performing primary care Our health care system will have to change to

meet our goal of an AIDS Free Generation

Roadmap for Medical Home Resource Center

PCMH concepts in RWCA Clinics– Action

Planning

Change Management of Improvement Opportunities

PCMH Certification

Strategic Planning Workshops

TA and Virtual Learning Community for practice change

TA to support certification

Year 1 Year 2 Year 3