Improving Population Health via PatientCentered Medical Homes

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Improving Population Health via Patient-Centered
Medical Homes

• Maximizing the value proposition and
  demonstrating it convincingly

Tracey Moorhead, CEO Gordon Norman, MD,
Chairman-elect June 12, 2008
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Evaluation Questions

• Is it beneficial? What benefits? For whom, when,
  why?
• Are benefits predictable, durable?
• Are the benefits replicable across different
  contexts, populations, time?
• Can these benefits be achieved cost-effectively?
  Where, when, how?
• Are cost savings possible? How much?
• When are savings likely? When not?
• Is benefit more related to what is done or who
  does it?
• What subject factors influence likelihood of
  benefits?
• What can we do better to improve value?

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Basic Assumptions

• Improved coordination of care and better
  integration of the care experience should produce
  measurable health improvements
• Proving these benefits is important in a zero-sum
  budget-constrained environment
• Long-term viability of funding for PCMH services
  may be contingent on compelling demonstration of
  sufficient offsetting value

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Relevant Value Dimensions

• Mortality
• Clinical outcomes
• Process of care measures
• Functional status/QOL
• Financial impact, cost-effectiveness
• Patient experience of care
• Provider experience of care

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Basic Evaluation Construct

• Compare population health with and without
  benefits of patient-centered medical home
• Prospective randomized study would deal best with
  potential biases, confounders
• Observational study with matched comparison group
  is a possible alternative
• Replication of favorable outcomes with robust
  methods is key to generalizability and
  credibility among academics, policymakers

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PHI Models Converging

• Many goals of PCMH, CCM, DM models of
  population health improvement overlap
• PCMH model can facilitate clinicians and DMOs
  collaborating to achieve mutual goals
• This creates opportunities for WIN-WIN alliances
  between provider organizations and DMOs to
  support key components of PCMH

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Supporting PPC-PCMH

• Access and Communication
• Patient Tracking and Registry
• Care Management
• Patient Self-Management Support
• Electronic Prescribing
• Test Tracking
• Referral Tracking
• Performance Reporting and Improvement
• Interoperability/Electronic Communications