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AHRQ and the Medical Home: Building a Blueprint David Meyers, MD Director, AHRQ Center for Primary Care AHRQ Annual Conference September, 2010. Disclosures. The speaker has no financial or other conflicts of interest to report. Disclosures.

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AHRQ and the Medical Home:Building a BlueprintDavid Meyers, MDDirector, AHRQ Center for Primary Care AHRQ Annual ConferenceSeptember, 2010

disclosures
Disclosures
  • The speaker has no financial or other conflicts of interest to report
disclosures1
Disclosures
  • The speaker has no financial or other conflicts of interest to report

(After all, I’m a bureaucrat)

bureaucrat
Bureaucrat
  • bu·reau·crat
    • 1.an official of a bureaucracy.
    • 2.an official who works by fixed routine without exercising intelligent judgment.
  • Or in my son’s words…
    • I go to a lot of meetings and spend my day reading and writing email.
session overview
Session Overview
  • Introductions and Welcome (5 minutes)
  • An Update on AHRQ’s Activities

in Support of the PCMH (15 min)

  • Perspective: Research Needs (10 min)
    • Debbie Peikes

Senior Researcher, MPR

  • Perspective: Implementer Needs (10 min)
    • Michael Barr

Vice President, ACP

  • Audience Response (40 minutes)
    • Where should AHRQ focus future activities in support of the PCMH?
  • Wrap-up (5 minutes)
goals
Goals
  • Participants will leave with an understanding of AHRQ’s activities in support of the primary care PCMH
    • Participants will see how feedback from their colleagues in 2009 has been incorporated into AHRQ’s activities
  • AHRQ will leave with a fuller understanding of the needs of its stakeholders
    • Researchers
    • Implementers
    • Policy-makers
    • American public
ahrq mission statement
AHRQ Mission Statement

To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

what ahrq does
What AHRQ does
  • Generates New Knowledge
the medical home
The Medical Home
  • AHRQ believes that the primary care medical home, also referred to as the patient centered medical home (PCMH), advanced primary care, and the healthcare home, is a promising model for transforming the organization and delivery of primary care.
  • Synthesizes Evidence
  • Supports Implementation
a home for the pcmh
A home for the PCMH
  • Center for Primary Care, Prevention, and Clinical Partnerships
    • Primary Care
      • PBRNs
    • Health IT
    • Prevention and Care Management
    • Mental Health / Primary Care Integration
primary care
Primary Care

AHRQ recognizes that

revitalizing

the Nation’s primary care system

is foundational to achieving

high-quality, accessible, efficient health care for all Americans.

the medical home1
The Medical Home
  • A medical home is not simply a place but a model of primary care that delivers care that is:
    • Patient-Centered
    • Comprehensive
    • Coordinated
    • Accessible, and
    • Continuously improved through a systems-based approach to quality and safety
the medical home2
The Medical Home
  • A medical home is not simply a place but a model of primary care that delivers the care that is:
    • Patient-Centered
    • Comprehensive
    • Coordinated
    • Accessible, and
    • Continuously improved through a systems-based approach to quality and safety
  • AHRQ believes that Health IT, workforce development, and payment reform are critical to achieving the potential of the medical home.
ahrq s definition of the medical home
AHRQ’s Definition of the Medical Home
  • http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_
ahrq and the joint principles closely aligned
Patient-Centered

Comprehensive

Team-based care

Coordinated

Accessible

Quality and safety

Health IT

Workforce development

Payment reform

Personal physician

Physician directed practice

Whole person orientation

Care Coordination

Health IT

Quality and safety

Enhanced access

Payment

AHRQ and the Joint Principles Closely Aligned

AAFP, AAP,

ACP, AOA

ahrq pcmh research
AHRQ PCMH Research
  • Retrospective Evaluations
    • Health Partners (Minnesota)
    • WellMed (Texas)
  • Mixed Methods Evaluations
    • Transforming Primary Care Practice
      • 14 2-year awards
      • $600K per study
      • Awarded summer 2010
  • Establishing a Research Agenda
    • Co-funded with CWMF and ABIMF
    • Collaboration of SGIM, STFM, APA
    • Results published June 2010 in JGIM
measurement
Measurement
  • Developing measures of care coordination in primary care
    • Care Coordination Measure Atlas
      • Collaboration of Battelle and Stanford
      • Released this week
    • Phase II of measure development 2010-11
measurement1
Measurement
  • Developing measures of care coordination in primary care
  • Planning for development of measure of ‘team-ness’
    • Multi-partner collaboration
    • Kick-off meeting held earlier this month
  • Measurement
    • Developing measures of care coordination in primary care
    • Planning for development of measure of ‘team-ness’
    • Developing a PCMH version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS)
      • Expected in 2011
synthesis
Synthesis
  • Foundational White Papers
    • Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes
    • Engaging Patients and Families in the Medical Home
    • Integrating Mental Health into the Medical Home
    • Developed in collaboration with Mathematica Policy Research and National Commission on Quality Assurance
synthesis1
Synthesis
  • Foundational White Papers
    • Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes
    • Engaging Patients and Families in the Medical Home
    • Integrating Mental Health into the Medical Home
    • Address Policy and Research Issues
necessary but not sufficient the hitech act s potential to build medical homes
Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes
  • While the meaningful use of Electronic Health Records (EHRs) helps support some aspects of the PCMH model, policy options available in HITECH and in broader health reform legislation could ensure EHRs are implemented in a way that will support primary care transformation.
necessary but not sufficient the hitech act s potential to build medical homes1
Necessary but Not Sufficient: The HITECH Act’s Potential to Build Medical Homes

Policy options include:

Adding explicit functionalities that directly support the PCMH model to the recently released EHR certification standards and criteria.

Adding meaningful use requirements that support the PCMH model for stages 2 and 3 of the EHR Incentive Program.

Funding the provision of technical assistance to primary care practices on PCMH transformation alongside the planned assistance on health IT adoption through Regional Extension Centers (RECs) or through a Primary Care Extension Service.

engaging patients and families in the medical home
Engaging Patients and Families in the Medical Home

How can policymakers ensure that the PCMH is responsive to and reflective of the goals, preferences, and needs of patients?

By promoting the involvement of patients and families in the medical home at three levels:

  • in their own care,
  • In practice-level quality improvement, and
  • In policy and research
engaging patients and families in the medical home1
Engaging Patients and Families in the Medical Home

Policy options include:

  • Requiring patient involvement to qualify a practice as a medical home
  • Using financial incentives to reward practices for involving patients and families
  • Supporting practices with technical assistance and tools
  • Ensuring Health IT is patient-focused
  • Incorporating patient input in the design, implementation, and evaluation of medical home pilot projects
  • Conducting additional research
integrating mental health into the medical home
Integrating Mental Health into the Medical Home
  • Normalize MH in mainstream medical practice – truly adopt a whole person approach to care.
  • Integrate reimbursement for the time and resources needed to provide MH treatment in the PCMH.
  • Develop performance measures to encourage adoption of integration while providing a source for ongoing feedback and improvement opportunities.
two additional reports
Two Additional Reports
  • Building Value: The Role of PCMHs and ACOs in Care Coordination
  • Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care
synthesis2
Synthesis
  • Database of published literature on the medical home
    • Over 500 citations
    • Searchable by PCMH domain, policy relevance, and outcomes
    • Includes a section on foundational documents and articles
synthesis3
Synthesis
  • Planned white papers for 2011:
    • Analysis of PCMH outcomes
    • Exploration of PCMH within the larger health care system
    • With potential for additional topics
  • Upcoming series of briefs on the status of primary care in the US
    • Includes new analysis of the primary care workforce
  • Toolkit on integrating the CCM in safety net setting
    • Visit: http://www.ahrq.gov/populations/businessstrategies/
    • Companion toolkit on utilizing practice coaching
      • Visit: http://www.ahrq.gov/populations/businessstrategies/coachmanl.htm
    • Currently conducting field evaluation
  • National learning collaborative around the use of practice facilitators and practice coaching
    • Launching fall 2010
implementation1
Implementation
  • Building a PCMH Information Model
    • Describe the PCMH in terms of the information flows and interactions between and among patients/consumers and other PCMH stakeholders
    • Develop new ‘functional use cases’
    • Examine current standards and existing ‘technical use cases’ in relation to the PCMH
    • Identify gaps
    • Contract awarded to Westat
    • Began Summer 2010
opportunities
Opportunities
  • 2010 Affordable Care Act:
    • Section 3502: Establishing community health teams to support the patient-centered medical home
    • Section 5405: Primary Care Extension Program

Both sections authorized without the appropriation of funds

putting it all together
Putting it All Together
  • Research
  • Measurement
  • Evidence Synthesis
  • Evidence-informed Policy Options
  • Implementation
dissemination
Dissemination

PCMH.AHRQ.Gov

pcmh ahrq gov
PCMH.AHRQ.Gov
  • Targeted towards meeting the needs of Policy Makers and Researchers
  • Includes:
    • AHRQ definition of the medical home
    • Searchable article database
    • Foundational white papers
      • Health IT
      • Patient and Family Engagement
      • Mental Health Integration
      • And additional reports
pcmh ahrq gov1
PCMH.AHRQ.Gov
  • Targeted towards meeting the needs of Policy Makers and Researchers
  • Includes:
    • AHRQ definition of the medical home
    • Searchable article database
    • Foundational white papers
  • Will continue to grow and expand
pcmh ahrq gov2
PCMH.AHRQ.Gov
  • Targeted towards meeting the needs of Policy Makers and Researchers
  • Includes:
    • AHRQ definition of the medical home
    • Searchable article database
    • Foundational white papers
  • Will continue to grow and expand

Please visit and help us spread the word

federal collaboration
Federal Collaboration
  • AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care
federal collaboration1
Federal Collaboration
  • AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care
  • In response, AHRQ convened a Federal Collaborative on the PCMH
    • Share information so that participants have a common understanding of PCMH
    • Foster collaborations and share expertise
thank you
Thank You
  • One minute for clarifying questions…
  • Research Needs and the Needs of Researchers
    • Remarks from Debbie Peikes, Ph.D.
      • Senior Researcher at Mathematica Policy Research
      • Visiting Lecturer at Princeton University
the patient centered medical home research needs and the needs of researchers

The Patient-Centered Medical Home: Research Needs and the Needs of Researchers

September 27, 2010

AHRQ Annual Conference

Bethesda, MD

Debbie Peikes, Ph.D.

we need good evaluations
We Need Good Evaluations

Payers/insurers: Will the PCMH reduce costs enough to cover the payments to providers and in-kind supports?

Practices: Transformation requires staffing, IT changes, time, and $. Will these translate into more satisfaction, $?

Patients: Will experience and outcomes improve? Will premiums fall?

Vendors: Will this movement exist in 5 years?

42

the pcmh model is promising but risky
The PCMH Model is Promising. . . but Risky

Risks:

Model isn’t actually implemented fully

Model is implemented, but does not work

Increases costs

Decreases satisfaction of patients

Decreases provider satisfaction

Decreases quality

Simply proceeding without evidence may divert resources from other primary care transformations that would work

43

what can an evaluation deliver
What Can an Evaluation Deliver?

Document whether the PCMH model was implemented

Identify barriers and facilitators to being a medical home

Assess effectiveness to justify investment

Measure performance to reward providers differentially

Guide replication of successful features

44

how do practices evolve into medical homes
How Do Practices Evolve into Medical Homes?

Efforts needed to reach MH criteria (time, internal and external resources, $)

Limits, potential of health IT

Ease of changing staffing and workflows

Resources required from outside the practice

Best practices and models

For patient outreach, recruitment, and engagement

For coordination

For chronic care, etc.

45

what is the impact of the pcmh
What Is the Impact of the PCMH?

Disease-specific and population-based quality of care measures

Process: Evidence-based care (e.g., foot exams for patients with diabetes)

Outcomes: Ambulatory-care sensitive complications

Coordination of care (harder to measure)

Patient experience

Provider experience

If providers are worse off, they won’t want to do this

Service use and cost

If this isn’t cost neutral or cheaper, payers won’t play

46

current research evidence is weak
Current Research Evidence is Weak

Well designed studies are not testing the full medical home (e.g., Guided Care, GRACE), or do so in a closed system (Group Health), or don’t have access to cost data (NDP)

Many studies are poorly designed, or do not report methods (e.g., North Carolina)

Many planned studies are too short, have not represented the counterfactual, do not address clustering, and are underpowered

47

research needs
Research Needs

Standardized measures of different medical home models to test variants

Fair comparison groups-similar before the intervention

At the practice level

At the patient level

Consider random assignment, staggered rollouts

Information on best claims-based approaches to attribute patients to their practices

Adequate follow-up

Need time to allow transformation to happen

Most evaluations are using only 1.5–2 years

Statistical techniques that account for clustering at the practice level

Not doing so will give false positives

Large sample sizes

We may erroneously find no effect because practices don’t have enough time to change or there isn’t enough sample to detect change

Costs vary so much it is difficult to separate intervention effects from random noise (this affects P4P too!)

Data repositories and guidelines for cross-walking all payer claims data

Well defined intermediate and final outcome measures that are comparable across studies

49

feedback from the front lines
Feedback from the Front Lines
  • Remarks from Michael Barr
feedback from the front lines1

Feedback from the Front Lines

AHRQ Annual Meeting

September 2010

Michael S. Barr, MD, MBA, FACP

Senior Vice President

Division of Medical Practice, Professionalism & Quality

202-261-4531

[email protected]

disclosure of conflicts of interest

Disclosure of Conflicts of Interest:

Grant funding from Pfizer and UnitedHealthGroup to support program development (ACP Medical Home Builder)

Quality improvement programs sponsored by pharmaceutical companies as part of ACPNet & ACP Closing the Gap

what physicians hear
What ^ Physicians Hear…

Some

Patient-Centered Medical Home

Health Care Home

Person-Centered Health Care Home

Meaningful Use

Certified EHR Technology

Complete EHRs

EHR Modules

Accountable Care Act (PPACA, ACA)

Maintenance of Certification

Physician Quality Reporting Initiative – PQRI

HITECK

E-prescribing Incentive Program

what physicians see
What ^ Physicians See…

Some

Drawing by: M.C. Escher

what physicians say
What ^ Physicians Say…

Some

Honestly, I have given up on all my professional organizations - they simply cannot or will not understand the point of view of the solo practitioner.

Haven\'t we given up enough of our autonomy? Aren\'t enough non-physicians in control of our destiny as it is?

I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession.

…the complex requirements of "meaningful use" mainly serve the EHR companies (who, not surprisingly, had a hand in developing the rule).

listening session
Listening Session
  • We invite members of the audience to share their observations and recommendations with AHRQ
    • Our primary goal is to learn from you what you see as the role for AHRQ moving forward
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