university of california, san francisco the 10 building...
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Department of Family & Community Medicine
Department of Family & Community
MedicineUniversity of California,
San Francisco
The 10 Building Blocks of High Performing Primary Care and
the Quadruple AimKevin Grumbach, MD
CHSPR Conference
March 9, 2017
Department of Family & Community Medicine
Presentation Overview
• Context of Canadian and US health care
• The imperative of primary care practice reform and transformation
• The UCSF Center for Excellence in Primary Care transformation model:
– The 10 Building Blocks of High Performing Primary Care
• Implications for policy and practice in BC
2
Commonwealth Fund International Scorecard
3
@kgrumbach lies. US health care great. Best in world. Except for
#Obamacare nightmare. @CHSPR SAD.
1m
Who needs #familydoctors anyway. My #PCP is a
#gastroenterologist. HEALTHIEST POTUS EVER!
1m
6
Nous, les Canadiens, faisons de notre mieux. Au moins,
nous avons un système civilisé d'assurance maladie
universelle.
2m
We Canadians are trying our best. At least we have a
civilized system of universal health insurance.
2m
7
Merci @CHSPR @kgrumbach. J‘ nos médecins de
famille. Bonne santé!
2m
Thanks @CHSPR @kgrumbach. I our family doctors.
To good health!
2m
88Did Not Get Same- or Next-Day Appointment Last Time You Needed Care
1922
31
41 41 42 43 4447
5053
0
20
40
60
80
100
NETH NZ AUS SWE UK US SWIZ FRA GER NOR CAN
Source: 2016 Commonwealth Fund International Health Policy Survey
Percent
Base: Excludes adults who did not need to make an appointment to see a doctor or nurse8
Multiple Chronic Conditions
Palliative Care Dementia Long-Term Home Care
Services
Social Services in the Community
Severe Mental Health Problems
Substance Use-Related Issues
AUS
CAN
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Doctors’ Views of Practice Preparedness to ManagePatients with Complex Needs
9
Base: Excludes doctors who report that they "never“ see these patients.
Source: 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
>75% of doctors reporting “well-prepared” >25% and ≤ 75% of doctors reporting “well-prepared” ≤ 25% of doctors reporting “well-prepared”
Top 2 countries in each category
How Stressful is Your Job as Primary Care Physician?10
Source: 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
1724
18 18 19 1712 12
6 5
6455
58 56 5352
44 42
37 36
18 21 24 24 27 31
43 4556 59
0
20
40
60
80
100
NETH AUS NZ NOR CAN SWIZ US GER SWE UK
Not too/Not at all Stressful Somewhat Stressful Extremely/Very Stressful
Burnout By Specialty
Source: Shanafelt TD et al. ArchInternMed.2012.3199
Mean
burnout, US
employed
adults
Gen Int Medicine
Family Medicine
11
Department of Family & Community Medicine
The Quadruple Aim
Department of Family & Community Medicine
The New Math of the 15 Minute Primary Care Visit
• A primary care physician with a panel of 2500 average patients would spend:
– 7.4 hours per day to deliver all recommended preventive care [Yarnall et al. Am J Public Health 2003;93:635]
– 10.6 hours per day to deliver all recommended chronic care services [Ostbye et al. Annals of Fam Med 2005;3:209]
13
Department of Family & Community Medicine
A 20th Century Model of Primary CareWill Not Meet the Demands of 21st
Century Health Care
Department of Family & Community Medicine
Primary Care Practice Transformation
• Patient-Centered Medical Home (PCMH)
• Advanced Primary Care
• High Performing Primary Care
15
Department of Family & Community Medicine 16
Department of Family & Community Medicine
What are the key characteristics and properties of primary care
practices that are high performing?
17
Department of Family & Community Medicine 18
Developing the building blocks of
the high-performing primary care practice
• Site visits and case studies of 23 highly regarded primary care practices across diverse regions and settings in the US
• Our experiences coaching 25+ practices in improvement
• From our observations, we extracted 10 Building Blocks -- the foundation of these practices
• The Building Blocks are a guide to improvement for primary care
Department of Family & Community Medicine 19
Clinica Family
Health Services
Group Health Olympia
Multnomah
County Health
Dept
South Central
Foundation
Univ of Utah-
RedstoneNewport News
Family Practice
Cleveland Clinic-
Stonebridge
Quincy, Office of
the Future
West Los Angeles-
VA
La Clinica de
la Raza
Clinic Ole
Sebastopol
Community
Health
Martin’s Point-
Evergreen Woods
Harvard Vanguard
MedfordBrigham and
Women’s and MGH
Ambulatory
Practice of the
Future
North Shore
Physicians GroupMedical Associates
Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont
Clinic
Mayo Red Center
Allina
23 high-performing practices
Source: Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 building blocks of high-performing primary care. Annals of Family Medicine, 12(2), 166.
Department of Family & Community Medicine
10 Building Blocks of High-Performing Primary Care
T Bodenheimer et al AnnFamMed March 2014
Department of Family & Community Medicine
10 Building Blocks of High-Performing Primary Care
T Bodenheimer et al AnnFamMed March 2014
Department of Family & Community Medicine
If practice leaders are not motivated and committed to a reformed practice model, change will not happen. • Mutual self-interest
– If not a burning platform, at least an uncomfortable temperature
– Incentives
• Culture
• Tools, resources, support
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Department of Family & Community Medicine
10 Building Blocks of High-Performing Primary Care
T Bodenheimer et al AnnFamMed March 2014
Department of Family & Community Medicine
Data are required to measure performance against goals and for accountability• Quadruple aim metric framework
• Process, outcomes, experience
• Challenge of relevant measurement in primary care
– Whole person care more than sum of disease specific items
– “Study to the test”
24
Department of Family & Community Medicine
Empanelment is an Enabler of Other Building Blocks
25
Essential for alternative PC payment models involving capitation/panel based payment
Department of Family & Community Medicine
Empanelment is an Enabler of Other Building Blocks
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Essential for alternative PC payment models involving capitation/panel based payment
Department of Family & Community Medicine
Team Members Aligned with Patient Population Needs
27
Health Coaches
Nurse, social worker, pharmacist, Beh Health, PT, etc
Reengineered role of the medical assistant
3° Care
1° Care
2° Care
Medical
Neighborhood
Medical Home
This is a health system
28
Department of Family & Community Medicine
Department of Family & Community Medicine
The Learning Health System
US Institute of Medicine definition of a Learning Health System: “one in which knowledge generation is so embedded into the core of the practice of medicine that it is a natural outgrowth and product of the healthcare delivery process and leads to continual improvement in care.”
Department of Family & Community Medicine
Michael Pollan’s Guide to Nutrition
• Eat food
• Not too much
• Mostly plants
Department of Family & Community Medicine
Kevin’s Guide to Health Care
• Get medical care
• Not too much
• Mostly primary care
