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AAFP AAP ACP AOA Joint Principles of the Patient-Centered Medical Home Rosemarie Sweeney MPA Vice President, Public Policy and Practice Support American Academy of Family Physicians. Patient Centric Primary Care Roundtable. Primary Care

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patient centric primary care roundtable
AAFP AAP ACP AOA

Joint Principles of the Patient-Centered Medical Home

Rosemarie Sweeney MPA

Vice President, Public Policy and Practice Support

American Academy of Family Physicians

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Primary Care

The provision of first contact, person-focused ongoing care over time that meets the health—related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive service services at other levels of care.

Starfield 09/04

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Most primary care in the US is provided by physicians who have completed residency training in family medicine, generalinternal medicine and pediatrics.Patient Centric Primary Care Roundtable
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Why is Primary Care Important
  • Better health outcomes
  • Lower costs
  • Greater equity in health

Starfield 09/04

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Patients who have an ongoing relationship with a primary care physician have better outcomes and lower costs (1)
  • When care is managed effectively in the ambulatory setting by primary care physicians, patients with chronic diseases like diabetes, CHF, and adult asthma have fewer complications, leading to fewer avoidable hospitalizations (2)
  • Starfield, presentation to Commonwealth Fund Roundtable on Primary Care, October 2006
  • Commonwealth Fund, Chartbook on Medicare, 2006
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What is the patient centered medical home?

Joint principles from AAFP, AAP, ACP and AOA outline the model, attributes, and payment structure

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Each patient has an ongoing relationship with a personal physician rained to provide provide first contact, continuous and comprehensive carePatient Centric Primary Care Roundtable
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The physician directed medical practice works as a team of individuals who collectively take responsibility for the ongoing care of patients
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Whole person orientation

The medical home provides for all the patient’s health care needs or takes responsibility for arranging care with other qualified professionals

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Care for all stages of life
  • Acute care
  • Chronic care
  • Preventive services
  • End of life care
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Care is coordinated across health care system and community
  • Subspecialty care
  • Hospitals
  • Home health
  • Nursing home
  • Family
  • Community based services
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Care is facilitated by:

-Registries

-Information Technology

-Health Information Exchange

using systems-based approaches to improve care coordination and management

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Quality and Safety are Hallmarks of the medical home

- Patient Centered Outcomes

- Evidence-based medicine

- Clinical decision support tools

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Physicians engage in continuous quality improvement and performance measurement and improvement

Information technology supports optimal patient care, performance measurement

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Convenience for patients

- Open scheduling (same day appointments)

- Extended hours

- Email communication, phone

consults, etc.

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Accountability to patients and payors

Practices participate in a voluntary recognition process to demonstrate they have the capabilities to provide services of the patient centered medical home

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Assures accountability to the purchaser (employer) and the consumer (employee) on quality, patient satisfaction and cost of care measuresPatient Centric Primary Care Roundtable
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Care management work that falls outside the office visit
  • Care coordination within practice and between consultants, other providers
  • Adoption and use of HIT for quality improvement
  • Provision of enhanced communication (email, phone consultation)
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Payment Structure

Fee for service for face to face visits

Care management fee to recognize added value

Additional payment for achieving measurable and continuous quality improvement

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RESULTS:
  • Employees will get better care
  • Employees will have higher patient satisfaction
  • Employees may need to take less time off from work
  • Employers will have lower costs
Patient Centric Primary Care Roundtable
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