Primary Care Renewal: Spreading Medical Homes

1
Primary Care RenewalSpreading Medical Homes

• David Labby MD
• Medical Director -- CareOregon
• Director of Clinical Support and Innovation

Rebecca Ramsay BSN, MPH Senior Manager of Care
Support and Clinical Programs -- CareOregon
Alan Glaseroff MD Chief Medical Officer
Humboldt County IPA
2
Objectives

• This session should help you
• Engage multiple organizations in a
  transformational initiative
• Spread a medical home model within practices
• Design new payment methodologies to foster
  continuous learning and population health
  improvement
• Build in practice care management programs for
  targeted risk populations

3
CareOregon
Our Vision Healthy Oregonians regardless of
their income or social circumstances.

• State Funded Health Plan for vulnerable
  citizens
• Medicaid Moms and Children, Disabled/
  Chronically Ill
• Medicaid/ Medicare Special Needs Plan
• Responsible For All Physical Health Care Costs
• Mental Health Paid Separately
• 115,000 Members
• Not for Profit
• Contracted network
• 50 Government Supported
  Community
  Health Centers
• Diverse Private Primary Care Practices
• Major metro and rural hospitals

Bruce Davidson
4
Primary Care Renewal

• Medical Home Initiative starting 2007 with 5
  primary care organizations
• Funded and organized by CareOregon, starting with
  5 clinic based pilot teams in 2007 and moving
  to organization wide spread
• Chartered and organized as a collective effort
  co designed learning collaborative -- not
  Health Plan directed
• Model for other initiatives in Oregon and
  California
• Medical Home payment model starting Jan 2009
• Key for ongoing success medical home as
  cultural transformation not simply structural
  transformation.

5
CareOregon Triple Aim for Survival

• Near bankruptcy in last recession (2002-3)
  population outcomes as business strategy
• Articulated by Berwick and Nolan in 2007 as
  Triple Aim
• Integrator Organizations
• Striving to optimize all three dimensions of
  Triple Aim
• Linking different currently fragmented components
  into a virtual system
• Primary care medical system for population
  health

IHI Technical Brief May 2007
6
CareOregon/ Southcentral Foundation Delegation
August 28-31, 2006
Why cant our community have the best health
care in the world? The best health
outcomes? How do we create intentionality in
everything we do? How do we create the caring,
knowledgeable relationships fundamental to health
and healing?
7
Primary Care Renewal

• SCF Experience Powerful vision takes us from
• Should we do it to How can we not do it?
• SCF Model Agreed Basic Design Principles
• Customer Driven Care
• Team Based Care
• Proactive Panel Health Improvement
• Integrated Behavioral Health
• Barrier Free Access
• Commitment to continuous learning and
  intentionality
• Process Improvement Training for all
  participants, Coaches
• CareOregon funding for clinic pilot teams

8
Creating ChangeWhos In Charge? (Really)

• No command and control over network
• No consensus on definition of medical home or
  blueprint
• Recognizing we are trying to hit a target with a
  bird and not an arrow

9
Building A Learning Collaborative

• Charter Meeting Agree on Vision
  
  and Core Principles
• Freedom to explore how principles
  
  implemented based on context.
• Step into the work collectively
• Breakthrough Series Collaborative with
  
  Pilot care teams
• Create emergent new knowledge through
  
  practice
• Establish a learning system
• Lead with principles, follow with tools and
  measures
• Emphasis on high yield change methods
• Model for Improvement/ PDSA cycles
• Transformation as culture change
• Foster intentionality vs ritualism
• Ask what really matters?
• Its not about structural change, but
  
  continuously improving individual
  and community outcomes

10
PCR History 2007 - 2009
11
Wild animals
Biting flies
Team
Swamp
Clinic
Population
Prophets
Rapids
Gold!

• Clinic (Yr 2-3)
• Spread?
• In clinic, X clinic
• Leadership
• PCR Steering Ctte
• Clinic Structure?
• Team Coaching
• Clinic data
• New Payment model
• Learning System?
• Standardization?

• Pilot Team (Yr 1)
• Team?
• New Roles
• Coaches, BHC, Care Mgrs
• Learning Groups
• Panels!!!
• Panel data
• Division of Labor
• Top of License
• Team Practices and Workflows
• Huddling, Meeting, Scrubbing
• BTS Collaborative

• Population (Yr 2.5- )
• Primary Care Accountability?
• What health, experience, cost outcomes?
• New Skills Competencies
• Care Management Collaborative
• Sub population Needs?
• New Partnerships
• Integration with other services

12
Co Designed Payment Pilot 1.0

• Quarterly payments to PCR medical home clinics
  based on member assigned, beginning Jan 2009
• Variable payment based on cumulative scoring
• Tier 1 Pay for improvement capacity
• Participate in PCR Collaborative, workgroups,
  learning sessions
• Report all required data perform satisfaction
  surveys
• Risk adjustment for higher acuity population
• Tier 2 Pay for improvement
• Pay for target improvement in key measures
  (access, HEDIS)
• Pay for full participation in care management
  learning collaborative
• Tier 3 Pay for outcomes
• Pay for achieving Plan HEDIS Benchmarks
• Pay for decrease in ambulatory sensitive
  Hospital admits, ED visits
• Prediction Pay 100 full Tier 1 80 full Tier
  2 20 full Tier 3
• Initially weight dollars to Tier 1gt2gt3

13
, 2009
14
PCR Medical Home Payment Model Metrics Pilot
Year Results
Q4 2008
Jan Mar 2009
Apr Jun 2009
July Sept 2009
15
0 - 10 rating of My Health Care Team
Patient Experience of Care Survey PCR May 2009
Less consistent Patient-Centered Care lowest
care ratings Mean score on 0-10 point scale (p
.000)
16
Current PCR Issue
VS
Credits Mindy Statlander/ Amit Shah
17
Adaptive Organizational Eco Cycle
http//www.plexusinstitute.org/edgeware/archive/th
ink/index.html
18
The Transformational Organization

• Technical Change

• Adaptive Change

• Define, spread Best Practice
• Use Methods and Measures that standardize and
  improve work
• Monitor to benchmarks

• Create environments and experiments that allow
  patterns to emerge
• Use methods that help generate ideas open up
  discussion, develop vision, encourage diversity/
  dissent, monitor emergence

Technical
Adaptive
Snowden, Boone, A Leaders Framework for Decision
Making. Harvard Business Review Nov 2007,
adapted.
19
PCR Change Packages

• Sustaining Team Care Panels
• Developing Accountable Care Teams
• Others in draft

• Purpose
• Define core PCR practice components
• For each component, create common understanding
  of
• Assumptions
• Purpose
• Principles
• Key practice elements
• Management metrics
• Learn about different operational solutions that
  deliver equivalent or better practice
  functionality
• Use
• Help guide effective implementation of
  transformational PCR practices
• Inform the design of a PCR payment model and
  state/national discussions on payment reform

20
Medical Home What We Know
and Dont Know

• Better Medical Services

• Better Population Outcomes

• Better (Advanced) Access
• Better service Efficiency (planned care etc)
• Increased Service Reliability (registries with
  gaps)
• Better Division of Labor (Teams)
• More comprehensive care (integrated BH?)
• What is the best way to do the work we currently
  know and do?

• What produces best Health?
• PC Role vz Community Health
• Optimal Delivery Model
• Optimized health care costs
• Integration across physical/ mental/ social care
• Increased patient/ community health self efficacy
• Triple Aim Measures
• What really matters? How should we redefine our
  work?

21
PCR 2010

• Medical Home Payment 2.0 Improving Outcomes
• Defined Entry Criteria based on performance
• Payment open to any network practice meeting
  criteria
• Multiple improvement metrics to allow different
  paths for development
• Targeted ED, Hospital follow up goals
• Transformational Learning System
• Completion of PCR Change Package 1.0
• Spread of Lean system tools
• Leadership Development Learning Collaborative
• Care Management Collaborative

22
Technical And Adaptive Synergy

• Technical

• Adaptive

Patient Centered Medical Home A better primary
care platform
23
The innovative applications really transform our
experience
24
Aligned with the Chronic Care Model
Comprehensive Medical Home Model
Advanced Medical Services Model
We are still figuring this out.
This is where much of the work has been focused.
25
CareOregons CareSupport Program
26
Primary Care Population Health Applications

• Care Coordination
• Problem Solving
• Linking with Community Resources
• Empowerment and Education

• Self Management Support
• Patient Education
• Patient Activation

• Registries
• Gaps in Care
• Planned Visits

1.Panel Management 2. Care Management for
3. Complex Case Management
Chronic Dz
Usual Care in Medical Home
New Potential for Medical Home to Transform
Patient Health Outcomes
27
Care Management/Case Management Competencies for
the Medical Home

• Population Orientation focused on entire panel,
  risk stratification and segmentation for outreach
  and intervention
• System Thinking what are the holistic needs of
  this patient
• Patient Driven RESPECT for patients guiding
  not directing and empowering not saving
• Creative Problem Solving thinking outside the
  box meet care needs
• Motivational Interviewing or other behavioral
  modification approach to self management support
• Health Literacy Principles in All Interventions
• Making the time, time, time has to be an
  explicit clinical role

28
Care Management Learning Collaborative
29
Lessons Learned from PCR Care Management Learning
Collaborative

• Care managers were engaged and enjoyed learning
  new skills, butthe clinic infrastructure had not
  changed enough to support this new practice
• Needed more physician and management input and
  participation
• Care management needs to be part of the value
  equation for the clinics
• They want to do it, but its not perceived as a
  need
• Health plans have a need because we have found
  that care management effects our bottom line
• If the clinics were at risk, it would happen

30
The current state of care management in the
medical home.

• Weve been looking around at different models,
  and there are essentially three variations
• Centralized health plan care managers
• CareOregon (currently shifting to the other two
  models), Health Partners (MN), Independent Health
  (NY)
• Health plan care managers embedded in clinics
• Geisinger Health Plan and UPMC (PA), Group Health
  Cooperative (WA) complex case managers,
  Hopkins Health Care Guided Care Model (MD),
• Clinic care managers supported by health plan via
  payment reform or staff model salaries
• Priority Health (MI) payment reform, Group
  Health Cooperative (Washington) staff model,
  Capital Health Plan ( Florida ) staff model

31
Learning how to plug in care management in our
medical home practices
Use new resources
Transform existing resources
Pilot Clinic
Mentoring
Start with DM and Depression

• CareOregon Provides
• Pilot team learning collaborative
• Payment model incentives

• CareOregon Provides
• Experienced resource
• Payment model incentives

32
PCR in Humboldt CountyA Regional Collaboration
to Improve Population Health, Individual Patient
Experience, and Lower the Total Cost of Care

• Alan Glaseroff MD, CMO
• Humboldt Independent Practice Association
• IHI National Forum
• Dec 9, 2009

33
A Little Assembly Required

• The person who invented the wheel was pretty
  smart, but the person who invented the other
  three was a genius!
• Uwe Rheinhart, Princeton Health Economist

34
Patient Driven Care

• Patients are the most important factor in their
  own outcomes
• Patients receive care from someone they know and
  trust
• Patients are able to access information directly
• What is the role of the care team in this
  Reformation?

35
Humboldt

• IPA
• Started in 1996
• 350 member IPA (210 physicians, 80 mid-levels, 60
  mental health professionals)
• 7,500 HMO members, 4,000 PPO and self-funded
• gt 95 of all providers including safety net,
  average practice size 3 MDs
• 84 PCPs
• BOD 50/50 PCPs and specialists
• Unaffiliated with hospitals
• Humboldt Diabetes Project 83 of all pts with DM
  in registry NCQA Recognition for DM 2004
• Butplateauted results by 2008

36
Practice Environment in Humboldt

• 29 primary care practices in various sizes, types
  and stages of transformation (all in the Humboldt
  IPA)
• 2/3 of patients receive care in either FQHCs or
  Rural Health Clinics
• 5 community health centers, Mobile clinic, United
  Indian Health
• Many rural health clinics (small practices)
• Many 1-3 clinician practices in private practices
  (one 17 MD Internal Medicine practice)
• No large integrated multispecialty group
• Managed care covering 5 of population
• How to transform care when we cover 10 of
  population?

37
Primary Care Renewal in Humboldt

• Trip to Group Health/Factoria and Care Oregon
  August 2008 to look at Medical Home/Care Support
  projects Build Your Own so we did
• Ed Wagner launch 11/08
• 14 teams 1/08
• Added peer-educator team (POET) 10/09
• Model for Improvement meets 5 Aims
• Clinician permission
• Starts with team mtgs (process measure for
  collaborative)
• MAs as medical professionals

38

• Team mtgs Front-line staff empowerment
• Model for Improvement
• Pro-active Panel Management
• HEDIS measures, closing the loop
• Access
• ED visit comparative report and patient stories
• Patient-Driven/Integrating Behavioral Health
• POET-led session problem-solving from patient
  perspective

39
What We Have Learned So Far

• Exhortation/fear of exposure/incentives not
  enough Enlightened self-interest imagine the
  perfect clinical day(dream)
• Always start from the patients view
• Teams need
• Best practices
• Model for improvement
• Coaching
• Comparative data/feedback
• Workforce Development
• MA II curriculum/certification
• RN Care Support/Population Management
• Peer-educators/coaches/navigators

40
For More Info.
www.careoregon.org/pcr/ labbyd_at_careoregon.org rams
ayr_at_careoregon.org alang_at_hdnfmc.com Continue
this transformation conversation. Tweet us
_at_rebeccaramsay