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Primary Care for 21 st Century High Performance Health Systems. Potential to Improve and Opportunities to Learn HSRAANZ Conference, December 2011 Cathy Schoen, Senior Vice President The Commonwealth Fund www.commonwealthfund.org. Primary Care for 21 st Century Health Care Systems.

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primary care for 21 st century high performance health systems

Primary Care for 21st Century High Performance Health Systems

Potential to Improve and Opportunities to Learn

HSRAANZ Conference, December 2011

Cathy Schoen, Senior Vice President

The Commonwealth Fund

www.commonwealthfund.org

primary care for 21 st century health care systems
Primary Care for 21st Century Health Care Systems
  • Patient-Centered, High Performance Care Systems
    • Goals: Accessible, High Quality (Outcomes/Health) and Sustainable Costs
    • Primary care teams and “medical homes” potential
    • Insights from 2011 International Survey of adults with serious acute or ongoing chronic disease
    • Often shared concerns in diverse systems
    • “Medical homes” make a difference
  • Innovative models – U.S. examples
    • Teams
    • Information and new communication technology
  • Opportunities to learn from country initiatives
transforming primary care patient centered teams and care systems
Transforming Primary CarePatient-centered teams and Care Systems
  • Patients receive enhanced access to primary care, well coordinated by a team
  • Patients actively engaged (treatment decisions, care at home)
  • Teams use decision-support tools, assess performance & receive payment support
  • Linked to care continuum – care system; health focus

2020 Vision

Accessible

Patient Centered

Coordinated Care

patient centered care and care systems primary care foundation connected to care system
Patient-Centered Care and Care Systems: Primary Care Foundation Connected to Care System
insights from patient experiences from 2011 international survey in eleven countries
Insights from Patient Experiences from 2011 International Survey in Eleven Countries
  • Survey of “sicker” adults:
    • Serious acute or ongoing chronic care conditions
    • Recent hospital, surgery, serious illness, or fair/poor health
  • Eleven Countries:
    • Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, U.K., and United States
  • Often shared experiences in diverse care systems
    • Care coordination, safety, engaging patients
    • Medical homes (accessible, know patients, help coordinate care) make a positive difference
cost related access problems in the past year
Cost-Related Access Problems in the Past Year

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

out of pocket spending and problems paying medical bills in past year
Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year

More than US$1,000

OOP Costs

Serious Problems Paying or Unable to Pay Medical Bills

Percent

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

access to doctor or nurse last time sick or needed care
Access to Doctor or Nurse Last Time Sick or Needed Care

Same- or next-day appointment

Waited six days or more

Percent

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

after hours care and emergency room use
After-Hours Care and Emergency Room Use

Difficulty Getting After-Hours Care Without Going to the ER

Used ER in Past Two Years

Percent

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

experienced coordination gaps in past two years
Experienced Coordination Gaps in Past Two Years

Percent

* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

gaps in hospital or surgery discharge planning in past two years
Gaps in Hospital or Surgery Discharge Planning in Past Two Years

Percent

* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patient reported medical medication or lab test error in past two years
Patient Reported Medical, Medication or Lab-Test Error in Past Two Years

Percent

*Medical mistake, or wrong drug/wrong dose, incorrect lab test results, delay in hearing about abnormal lab test.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patient doctor relationship and communication
Patient-Doctor Relationship and Communication

Base: Has a regular doctor/place of care.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patient engagement in care management for chronic condition
Patient Engagement in Care Management for Chronic Condition

Base: Has chronic condition.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patients with a regular doctor vs medical home
Patients with a Regular Doctor vs. Medical Home

Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.

Percent

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patient doctor relationship and communication by medical home
Patient-Doctor Relationship and Communication, by Medical Home

Percent reporting positive patient-doctor relationship and communication*

* Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way that is easy to understand.

Base: Has a regular doctor/place of care.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patient engagement in care management for chronic condition by medical home
Patient Engagement in Care Management for Chronic Condition, by Medical Home

Percent reporting positive patient engagement in managing chronic condition*

* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.

Base: Has chronic condition.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

experienced coordination gaps in past two years by medical home
Experienced Coordination Gaps in Past Two Years, by Medical Home

Percent*

* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

hospital or surgery discharge planning gap in past two years by medical home
Hospital or Surgery Discharge Planning Gap in Past Two Years, by Medical Home

Percent*

* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

medical medication or lab test errors in past two years by medical home
Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home

Percent*

* Reported medical mistake, medication error, and/or lab test error or delay in past two years.

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

rated quality of care in past year as excellent or very good by medical home
Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home

Percent

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

patient centered coordinated primary care medical homes as part of systems approach
Patient-Centered, Coordinated Primary Care Medical Homes as Part of Systems Approach
  • Systems approach: Access, Quality, Efficiency
  • Primary care medical or “health” homes
    • Timely access to care: multiple points of access
    • Patient engagement in care
    • Information systems: quality & coordination
    • Routine feedback of patient and clinical outcomes
    • Coordinated care, creative use of teams
    • Incentives and system support to improve/innovate

Approach to redesigning primary care

    • Part of “system” of care the aims to organize care around patients and focus on outcomes
u s multiple models of medical homes and teams
U.S. Multiple Models of Medical Homes and Teams

Community Care of North Carolina

examples of cost and quality outcomes from primary care medical home interventions
Examples of Cost and Quality Outcomes from Primary Care Medical Home Interventions

Geisinger Health System (Pennsylvania)

  • 18 percent reduction in all-cause hospital admissions; 36% lower readmissions
  • 7 percent total medical cost savings
  • Mass General High-Cost Medicare Chronic Care Demo (Massachusetts)
  • 20 percent lower hospital admissions; 25% lower ED uses
  • Mortality decline: 16 percent compared to 20% in control group
  • 7% net savings annual

Guided Care - Geriatric Patients (Baltimore, Maryland)

  • 24 percent reduction in total hospital inpatient days; 15% fewer ER visits
  • 37 percent decrease in skilled nursing facility days
  • Annual net Medicare savings of $1,364 per patient
  • Group Health Cooperative of Puget Sound (Seattle, Washington)
  • 29 percent reduction in ER visits; 11% reduction ambulatory sensitive admissions
  • Health Partners (Minnesota)
  • 29% decrease ED visits; 24% decrease hospital admissions
  • Intermountain Healthcare (Utah)
  • Lower mortality; 10% relative reduction in hospitalization
  • Highest $ savings for high-risk patients
pennsylvania geisinger medical navigator home sites and hospital admissions readmissions
Pennsylvania: Geisinger Medical “Navigator” Home Sites and Hospital Admissions/Readmissions

Hospital admissions per 1,000 Medicare patients

Readmission Rates for All Medical Home Sites

As of Q4-2008*:

  • 18% reduction in hospital admissions
  • 36% reduction in hospital readmissions
  • 7% total medical cost savings

Source: Geisinger Health System, 2009. *Results reported in: R. Gilfillan et al, “Value and the Medical Home: Effects of Transformed Primary Care,” The American Journal of Managed Care, 16(8) 2010: 607-614.

slide27

Vermont: Shared Resources Community Teams

  • A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services
  • Multi Insurer Payment Reform that supports a foundation of medical homes and community health teams
  • A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry
  • An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact

Hospitals

Medical Home

Specialty Care & Disease Management Programs

Community Health Team

Nurse Coordinator

Social Workers

Nutrition Specialists

Community Health Workers

MCAID Care Coordinators

Public Health Specialist

Medical Home

Social, Economic, & Community Services

Medical Home

Mental Health & Substance Abuse Programs

Medical Home

Healthier Living Workshops

Public Health Programs & Services

Health IT Framework

Evaluation Framework

international innovations in access after hours early morning nights and weekends
International Innovations in Access “After-Hours” Early Morning, Nights and Weekends
  • Denmark
    • County wide physician cooperatives with phone and visit center
    • Computer connections to medical records
    • Reduce physician workload
  • Netherlands
    • 2000/2003: Cooperatives evening to 8 AM and weekends; Nurse led with physician available
    • House calls for emergencies
    • Reduce physician workload and use of emergency rooms
  • United Kingdom
    • Some cooperatives developing; walk-in centers
    • 24 Hour Help Line: NHS Direct

Source: Grol et al., “After-Hours Care in the U.K., Denmark, and the Netherlands: New Models,” Health Affairs, Nov./Dec. 2006; Schoen et al., “On the Front Lines of Care,” Health Affairs Nov. 2, 2006.

24 7 access dutch gp after hours cooperatives
24/7 Access: Dutch GP After-Hours Cooperatives
  • Since the 2000s, 127 GP cooperatives; cover more than 90% of the population
  • Access to after-hour primary care through single telephone number
  • Community physicians rotate; nurse staffed – phone and visit
  • Home visits with medically trained car drivers in fully equipped cars (e.g. O2, infusion drip, automatic defibrillation equipment)
  • Electronic health records; communication to regular GP

Source: J. Burgers, UMC St Radboud, Providing After-hours Primary Care in the Netherlands presentation at The Commonwealth Fund Harkness Alumni Policy Forum, May 20-22, 2011.

slide30

Visiting Nurse Service New York Health PlansPatient-Centered Care Teams for High-Cost Chronically Ill Medicare and Medicaid – Special Needs and Long Term Care

  • Interdisciplinary teams; home and community care; transition care
  • Care and assist with navigating complex health care systems
  • Patient-centered: targets and customizes interventions
  • Strong health information technology and EHR; Support team
  • Positive results
    • Improved primary care access; high quality and patient ratings
    • Reduce hospital admissions, readmissions, ER use (17 to 27%)
    • Links primary, specialist and long term care
    • Patient and family preferences

Summary of presentation by Carol Raphael, Pres and CEO, NY Visiting Nurse Assn., 6/2011

slide31

ED visits reduced 67%

  • Hospital admissions reduced 84%
  • Lost school days reduced 41%
  • Missed work days (Parents/caregivers) reduced 55%
  • Recipient of U.S. Environmental Protection Agency’s 2010 National Environmental Leadership Award in Asthma Management

Home visits • Medication education • Asthma management tools for patients • Understanding triggers and reducing triggers in the home • Connecting families to community resources

Source: http://www.childrenshospital.org/clinicalservices/Site1951/mainpageS1951P0.html

alaska dental health aide program improves access to oral health care
Alaska Dental Health Aide Program Improves Access to Oral Health Care
  • Began in 2003; first of its kind in the United States
  • High unmet need, particularly in rural communities
    • Dentist shortages
    • High rates of oral diseases
  • Dental therapists provide education, preventive services, and basic treatment in regional hub clinics and remote village clinics
  • Focuses on reaching children, pregnant women, and other high-risk residents
  • Evaluation: providing safe, competent, appropriate care

Dental Health Aide Therapist Program, Class of 2010

Student in clinic

Source: Alaska Dental Health Aide Therapist Initiative, Alaska Native Tribal Health Consortium. http://www.anthc.org/chs/chap/dhs/

slide34
Boston Mass. General Hospital: Care RedesignT. Ferris, G. Meyer, P. Slavin presentation to Commonwealth Fund 4-2011
hospital use of it to predict risk and marshal resources including transition care discharge
Hospital: Use of IT to Predict Risk and Marshal Resources, Including Transition Care/Discharge

Parkland, Texas: An EMR model to predict 30-day readmission for heart failure using SES risk and clinical risk. Model includes: systolic and diastolic blood pressure, pulse, temperature, pH, BNP, PT/ INR, glucose, CK-MB, troponin, wbc, pCO2, BUN, sodium, creatinine, CK, bilirubin, albumin, age, history of depression, single, male, no. of home address changes, medicare, high risk census tract, cocaine use, missed clinic visit, used pharmacy, prior inpatient admissions, ED presentation time. C-statistic: Derivation: 0.73; Validation 0.69

Source: Ruben Amarasingham, MD, Parkland Health and Hospital System, Presentation to Commonwealth Fund on May 12, 2010, “Harnessing Electronic Medical Record Data to Reduce Readmissions.”

telehealth electronic communication
Telehealth & Electronic Communication
  • North Dakota Telepharmacy Project – Reaching over 40,000 rural residents
  • E-consults and referrals
      • San Francisco General Hospital
      • The Mayo Clinic
      • Group Health
  • Veteran’s Health Administration– Scaling up Telehealth Services
tele health and electronic communication enhanced access and care teams
Tele-Health and Electronic Communication: Enhanced Access and Care Teams
  • Veteran’s Administration: serving 31,000 frail at home; aim to serve 92,000 by 2012
    • High patient ratings; Link to care teams – home visits
    • 40 percent reduction in “bed-days” by 2010 compared to start
  • U.Tennessee Memphis: Remote specialist consultations with patients, local clinicians. Center serves 3 state region
    • Reduce heart failure admission + readmissions by 80%
    • “real time” diabetic retinopathy (digital) report results
  • Primary care to Specialist e-consultations and referral
    • Mayo, SF General, Group Health Puget Sound
  • Kaiser : Web access, e-visits/consultation - outreach and booking
  • Henry Ford Detroit: Kiosks in churches, communities
keys to rapid progress

Payment Reform: Value

Information

Systems

Keys to Rapid Progress

Teams and Care System Redesign

primary care redesign
Primary Care Redesign
  • Primary Care Teams, including Long Term Care
    • Expanded set of skills; new work roles
    • Nurse and medical assistants new roles and skills
    • Education and training
    • Everyone “working to top of skill set”; learning
  • Shared resources include teams and information systems
    • Primary care and specialist linked through information systems: opportunities to learn, coach
    • Home care and long-term care nursing teams work with multiple practices
  • Scope of practice, delegation to enable teamwork
  • Prevention and population health: community health outreach
primary care health care system and population health
Primary Care, Health Care System and Population Health
  • Whole system view
    • Health and value gains if we use resources more creatively and productively
    • Primary care, teams, information, shared services, population health – beyond “facilities”
  • Focus on key areas
    • Transforming primary care, teams and care systems
    • Creative use of electronic health information systems and technology
    • Shared resources
    • Aligning Payment and Regulations with Value
slide41

Primary Care Innovation: Rich Opportunities to Learn from International Initiatives

Focused on Achieving Core Health Care System Goals

Better Population

Health

Better Care

Experiences

Slow or Reduce per

Person Costs

Institute for Healthcare Improvement (IHI) Triple Aim

for more information visit the fund s website at www commonwealthfund org
For More Information Visit the Fund’s website atwww.commonwealthfund.org

For survey results: C. Schoen, R. Osborn et al. “New 2011 Survey of Patients with Complex Needs Finds that Care Is Often Poorly Coordinated,” Health Affairs, Nov. 9, 2011 Web first

2011 survey profile of sicker adults
2011 Survey Profile of Sicker Adults

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.