The Patient Centered The Patient Centered Medical HomeMedical Home

Joseph E. Scherger, MD, MPHJoseph E. Scherger, MD, MPHSan Diego County Medical San Diego County Medical

SocietySocietyApril 9, 2009April 9, 2009

The Holy Grail for 2009The Holy Grail for 2009

Cost ReductionCost Reduction Improved Quality OutcomesImproved Quality Outcomes Improved Patient ServiceImproved Patient Service

The Secret Sauce for The Secret Sauce for SuccessSuccess

Care becomes Care becomes continuouscontinuous access rather than episodicaccess rather than episodic

Care becomes Care becomes proactiveproactive rather than reactiverather than reactive

Patients become activated for Patients become activated for self-managementself-management

The New MillenniumThe New Millennium Quality Chasm ExposedQuality Chasm Exposed Cost Inflation ResumesCost Inflation Resumes Consumer Driven Health CareConsumer Driven Health Care Primary Care Under StressPrimary Care Under Stress The Decade of Health The Decade of Health

Information Technology and Information Technology and Transformation in the Process of Transformation in the Process of CareCare

Current Clinical PracticeCurrent Clinical Practice Based on an Acute Care Model and Based on an Acute Care Model and

Physician Centered CarePhysician Centered Care Does not work well for Prevention Does not work well for Prevention

and Chronic Illness managementand Chronic Illness management Brief episodic visits must be part of Brief episodic visits must be part of

a continuous system of carea continuous system of care Longer visits needed for complex Longer visits needed for complex

patientspatients Multidisciplinary teams working as Multidisciplinary teams working as

a quality system of carea quality system of care

What’s Driving the Change?What’s Driving the Change?

Reprinted with permission from Davis et al for the Commonwealth Fund; May 2007. [permission pending.]

A Growing ProblemA Growing Problem

““I can’t do what I came to do – I can’t do what I came to do – help people through a variety of help people through a variety of difficult problems. I don’t have difficult problems. I don’t have the time to do the job right.”the time to do the job right.”

““We are not doing a good job, We are not doing a good job, and it’s not our fault. Our care and it’s not our fault. Our care model is faulty.”model is faulty.”

Outcomes in Outcomes in HypertensionHypertensionNHANESNHANES 19911991

JNC VIJNC VI 19971997

OlmsteaOlmsteaddCountyCounty 19991999

AwareAware 73%73% 68%68% 61%61%TreatedTreated 55%55% 54%54% 45%45%ControlleControlledd

29%29% 27%27% 17%17%

Only 27% of hypertension is adequately controlled.

27%

Only 26% of people with diabetes have blood pressures well controlled.

26%

Only 25% of people with depression receive treatment.

25%

50% of patients hospitalized with congestive heart failure (CHF) are

readmitted within 90 days.

50%

So What is Wrong?So What is Wrong?

Not What We Do,Not What We Do,But How We Do ItBut How We Do It

Our Process of Care is Our Process of Care is Ineffective and Ineffective and

ObsoleteObsolete

Why?Why?The Brief Visit Model is an The Brief Visit Model is an

Acute Care ModelAcute Care ModelWe Now Do Preventive We Now Do Preventive Care, Chronic Illness Care, Chronic Illness

Management, a Management, a Biopsychosocial and Biopsychosocial and

Family Systems Family Systems OrientationOrientation

The Ticking Clock in the The Ticking Clock in the Doctor’s OfficeDoctor’s Office

““Patients on routine visits Patients on routine visits to their primary doctors to their primary doctors often have lots of questions often have lots of questions but not enough time to get but not enough time to get good answers.”good answers.”

- - New York Times, New York Times, February 6, 2007February 6, 2007

““Hamster Healthcare: Time Hamster Healthcare: Time to stop running faster and to stop running faster and redesign health.”redesign health.”

- - Ian Morrison & Richard Ian Morrison & Richard Smith. BMJ. 2000;321:1541-Smith. BMJ. 2000;321:1541-

15421542

Hamster CareHamster Care

““Time spent with the physician Time spent with the physician is the strongest predictor of is the strongest predictor of patient satisfaction.”patient satisfaction.”

- Anderson RT, et al. - Anderson RT, et al. BMC Health Services ResearchBMC Health Services Research

The Time Problem The Time Problem Time Needed for Time Needed for

Chronic Illness CareChronic Illness Care Time Needed for Time Needed for

Preventive CarePreventive Care Time Needed for Time Needed for

Acute CareAcute Care Total face to face Total face to face

time for 2500 time for 2500 patientspatients

Ann Fam Med 2005;3:209Ann Fam Med 2005;3:209Am J Pub Health 2003;93:635Am J Pub Health 2003;93:635

10.6 hours a day 10.6 hours a day for 2500 patientsfor 2500 patients

7.4 hours a day7.4 hours a day

4.6 hours a day4.6 hours a day

22.6 hours/day22.6 hours/day

The Brief Visit Busy The Brief Visit Busy Office Schedule Office Schedule

Model of Ambulatory Model of Ambulatory Care Must Be Care Must Be

Replaced By a New Replaced By a New ProcessProcess

Care Does Not Equal VisitsCare Does Not Equal Visits

Optimal care is based on deep, trustful Optimal care is based on deep, trustful relationships between practice and patientsrelationships between practice and patients

Great relationship demands that we go far Great relationship demands that we go far beyond visits in delivering care to patientsbeyond visits in delivering care to patients

An outmoded way of managing patients

The medical office is a The medical office is a bottleneck of episodic bottleneck of episodic care that does a poor care that does a poor

job of managing job of managing chronic illness and chronic illness and

providing preventive providing preventive servicesservices

Office Practice – Core Office Practice – Core FunctionsFunctions

We Manage We Manage RelationshipsRelationships

We Manage KnowledgeWe Manage Knowledge We Manage ResourcesWe Manage Resources We Provide SkillsWe Provide Skills

Quality Ambulatory Care Quality Ambulatory Care For The 21For The 21STST Century Century

Freedom From ErrorFreedom From ErrorConsistent Best Consistent Best PracticePractice

Great ServiceGreat Service

Common Mistakes in Office Common Mistakes in Office PracticePractice

PrescribingPrescribing Missed DiagnosesMissed Diagnoses Missed Lab/X-ray dataMissed Lab/X-ray data Wrong TreatmentWrong Treatment ProceduresProcedures

ContentOverwelms

No Time to Read it All

Information OverloadInformation Overload

Future Office PracticeFuture Office Practice Management of a Population of Management of a Population of

PatientsPatients Patient-Centered CarePatient-Centered Care Personal Medical HomePersonal Medical Home Best Knowledge at the Point of Best Knowledge at the Point of

CareCare Continuous Access to Continuous Access to

Multimodal CommunicationMultimodal Communication

Future Office PracticeFuture Office Practice A New Platform of CareA New Platform of Care Fewer Time Intensive VisitsFewer Time Intensive Visits Group VisitsGroup Visits Teamwork and Interpersonal Teamwork and Interpersonal

SkillsSkills Financial Practice Financial Practice

ManagementManagement

Information Technology Changing Information Technology Changing MedicineMedicine

Patient InformationEHR , All Clinical Data

CommunicationDigital Connection of

Patients with Caregivers

Knowledge Management

and Decision Support Tools

The New Communication The New Communication PlatformPlatform

Interactive Web SiteInteractive Web Site Electronic Communication For:Electronic Communication For: Lab Results And Other DataLab Results And Other Data Chronic Illness CareChronic Illness Care Behavioral CoachingBehavioral Coaching Minor Acute ProblemsMinor Acute Problems Online Family MeetingsOnline Family Meetings

Increased Chronic Care Increased Chronic Care NeedsNeeds

About 150 million people (50% of About 150 million people (50% of population) have one or more chronic population) have one or more chronic conditionsconditions

Chronic conditions account for more Chronic conditions account for more than 75% of health care expenditures than 75% of health care expenditures

80/20 Rule: Limited number of 80/20 Rule: Limited number of conditions account for most of these conditions account for most of these health care expenditureshealth care expenditures

Improved Outcomes

Informed,Activated

Patient

ProductiveInteractions

Prepared,Proactive

Practice Team

Resources and Policies

Community

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health SystemHealth Care Organization

Chronic Care Modelhttp://www.improvingchroniccare.org

Planned CarePlanned Care Care is based on evidenceCare is based on evidence

Decision support is built into the work flowDecision support is built into the work flow Nothing drops through the cracksNothing drops through the cracks

Patient and Disease RegistriesPatient and Disease Registries Individual and Population based careIndividual and Population based care

Patient and care team are on the Patient and care team are on the same pagesame page

Patients are activated to better Patients are activated to better manage their conditionsmanage their conditions

Stepped-up care/resources tied to Stepped-up care/resources tied to patient needpatient need

What Is a Patient-Centered What Is a Patient-Centered Medical Home?Medical Home?

A Patient-Centered Medical Home A Patient-Centered Medical Home (PCMH) is a model for care (PCMH) is a model for care provided by physician practices provided by physician practices that seeks to strengthen the that seeks to strengthen the physician-patient relationship by physician-patient relationship by replacing episodic care based on replacing episodic care based on illnesses and patient complaints illnesses and patient complaints with coordinated care and a long-with coordinated care and a long-term healing relationship (NCQA).term healing relationship (NCQA).

Adapted from Joint Principles of the Patient-Centered Medical Home, March 2007. Available at: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.dat/022107medicalhome.pdf.

Patient Centered Medical Patient Centered Medical HomeHome

Proactive Care Proactive Care Coordination by a Team Coordination by a Team Separate From Office Separate From Office VisitsVisits

NCQA Recognition as a NCQA Recognition as a PCMHPCMH

Access and CommunicationAccess and Communication Patient Tracking and Registry Patient Tracking and Registry

FunctionsFunctions Care ManagementCare Management Patient Self-Management SupportPatient Self-Management Support Electronic PrescribingElectronic Prescribing Test and Referral TrackingTest and Referral Tracking Performance Reporting and Performance Reporting and

ImprovementImprovement Advanced Electronic CommunicationsAdvanced Electronic Communications

The Secret Sauce for The Secret Sauce for SuccessSuccess

Care becomes Care becomes continuouscontinuous access rather than episodicaccess rather than episodic

Care becomes Care becomes proactiveproactive rather than reactiverather than reactive

Patients become activated for Patients become activated for self-managementself-management

Concierge Care for Concierge Care for Everyone?Everyone?

Continuous AvailabilityContinuous Availability Focus on Comprehensive Care Including Focus on Comprehensive Care Including

PreventionPrevention Enhanced Professional and Patient Enhanced Professional and Patient

SatisfactionSatisfaction Is Concierge Practice the Custom Invention Is Concierge Practice the Custom Invention

that will lead to the Model of the Future?that will lead to the Model of the Future? American Society of Concierge Physicians is American Society of Concierge Physicians is

now the Society for Innovative Medical now the Society for Innovative Medical Practice DesignPractice Design

Make it Affordable Make it Affordable

A New Vision of Office A New Vision of Office PracticePractice

Responsibility for a Population of Responsibility for a Population of PatientsPatients

Manage Needs and Demands on a New Manage Needs and Demands on a New Platform of Services (Web Based)Platform of Services (Web Based)

Prioritize Conditions and use a Team Prioritize Conditions and use a Team ApproachApproach

Take the Time to be Effective (Time to Take the Time to be Effective (Time to Heal)Heal)

Change the Concept and Application of Change the Concept and Application of ProductivityProductivity

“The more you can move demand away from office visits, the more time you’ll have to deal with patients who really need personal interaction.”

--Donald Berwick, M.D.

DAILY SCHEDULE 2003Thursday January 30, 2003 Daily Schedule Dr.. Wellbetter

Time Patient Age/Sex Chief Complaint

8:00-9:00 AM HOSPITAL CARE9:00 AM Sipowitz, Stephanie 39 yo/F f/u fibromyalgia9:15 AM Washington, Pete 65 yo/M back pain9:30 AM Green, Jim 44 yo/M f/u swollen ankles,?? HTN9:45 AM Armstrong, Tile 32 yo/M f/u DM10:00 AM Jackson, Lawrence 58 yo/M New pt. CPE10:15 AM xxxx xxx xxx10:30 AM Jackson, Aretha 59 yo/F New pt. CPE10:45 AM xxxx xxx xxx11:00 AM Jacoby, Oswald 70 yo/M Loose cough, chest pain, ?? Pneumonia11:15 AM Pickles, Dill 9 mo/ M Diarrhea, rash11:30 AM O'Connor, Liam 26 yo/M headache,blurry vision, dizzy spells11:45 AM Peterson, Roosevelt 28 yo/M ETOH stopped drinking 3 days ago12:00 PM LUNCH1:00 PM Pitacki, Helga 12 yo/F miss'd sev d school,malaise, won't talk to parents1:15 PM Oliver, Emma 2 yo/F congestion, runny nose1:30 PM Vargas Antonio 4 yo/M won't sleep, ears hurt1:45 PM Vargas, Juan 4 yo/M won't sleep, ears hurt2:00 PM Vargas, Carlita 5mo/F chronic crying2:15 PM Burnbaum, Bertha 60 yo/F osteoarthritis2:30 PM Smith, Tillula 19 yo/F pelvic pain2:45 PM Crocker, Betty 48 yo/F minor burn3:00 PM Brady, Marsha 17 yo/F amenorrhea3:15 PM Kosokovitch, Edwina 90 yo/F f/u breast CA, needs interpreter3:30 PM Fairchild, Maddison 5 y/o F kindergarten school physical, needs shots3:45 PM Blackwell, Sophia 57 yo/F headache/depression4:00 PM Valdez, Juan 72 yo/M smoker, f/u (on patch)4:15 PM Halperin, Hanna 8 yo/F cough 3 days, no cold4:30 PM Blocker, Mike 20 yo/M rotator cuff pain, f/u requesting refill on Percocet4:45 PM Rodriguez, Minnie 23 yo/F 2 wk ppartum f/u5:00 PM Rodriguez-DelRey, Maria 2 wo/F 2 wk WWC5:30-7:00 PM CHARTING & PAPERWORK

Thursday January 30, 2006 Daily Schedule Dr.. Wellbetter

DAILY SCHEDULE 2006

Time Patient Age/Sex Chief Complaint

8:00-9:00 AM HOSPITAL CARE9:00-10:00 AM EMAIL & TELEMEDICINE

Blackwell, Sophia 57 yo/F headache/depression

Valdez, Juan 72 yo/M smoker, f/u (on patch)

Green, Jim 44 yo/M f/u swollen ankles,?? HTN

Vargas Antonio 4 yo/M won't sleep, ears hurt

Vargas, Juan 4 yo/M won't sleep, ears hurt

Vargas, Carlita 5mo/F chronic crying

Armstrong, Tile 32 yo/M f/u DM

10:00 AM Jackson, Lawrence 58 yo/M New pt. CPE

10:30 AM Jackson, Aretha 59 yo/F New pt. CPE

11:00 AM Jacoby, Oswald 70 yo/M Loose cough, chest pain, ?? Pneumonia

11:30 AM Pickles, Dill 9 mo/ M Diarrhea, rash

12:00 PM LUNCH1:00-2:00 PM INTERNET TELECONFERENCING W/FAMILIES

Kosokovitch, Edwina 90 yo/F f/u breast CA, needs interpreter

2:00 PM Blocker, Mike 20 yo/M rotator cuff pain, f/u requesting refill on Percocet

2:30 PM Peterson, Roosevelt 28 yo/M ETOH stopped drinking 3 days ago

3:00 PM Pitacki, Helga 12 yo/F missed sev days school, gen malaise, won't talk to parents

3:30 PM Fairchild, Maddison 5 y/o F kindergarten school physical, needs shots

4:00 PM Washington, Pete 65 yo/M back pain

4:30-5:30 PM HOME VISITSRodriguez, Minnie 23 yo/F 2 wk ppartum f/u

Rodriguez-DelRey, Maria 2 wo/F 2 wk WWC

A New Model of Office A New Model of Office PracticePractice

50% more caring interactions each 50% more caring interactions each dayday

10-12 unhurried office visits each day10-12 unhurried office visits each day Advanced access – do today’s work Advanced access – do today’s work

todaytoday Patients get all the time they needPatients get all the time they need Patients receive the latest treatmentsPatients receive the latest treatments

How?How?

An interactive practice website is a An interactive practice website is a new platform of communicationnew platform of communication

40-60% of patient needs handled 40-60% of patient needs handled onlineonline

Electronic medical record with Electronic medical record with imbedded knowledge management imbedded knowledge management toolstools

Great serviceGreat service

Financial Models for the Financial Models for the New ModelNew Model

Shift of telephone to E-mail (time saver, $ Shift of telephone to E-mail (time saver, $ neutral)neutral)

Reduce unnecessary visits (more $ in high Reduce unnecessary visits (more $ in high demand office, less $ in lower demand)demand office, less $ in lower demand)

Payment for virtual care (Web Visit Charges)Payment for virtual care (Web Visit Charges) Prepaid service fee, monthly ($30) or annual Prepaid service fee, monthly ($30) or annual

($360)($360) Prepaid Contracts Prepaid Contracts Pay for Performance incentivesPay for Performance incentives Billing for Group VisitsBilling for Group Visits

Finances Follow Finances Follow Innovation Innovation

The New Model is More The New Model is More EfficientEfficient

Better Faster Cheaper!Better Faster Cheaper!

Ideal Medical HomeIdeal Medical Home Pioneered by Gordon Moore as Pioneered by Gordon Moore as

Idealized Micropractice (IMP)Idealized Micropractice (IMP) Growing very fast in Family Growing very fast in Family

MedicineMedicine Convocation at AAFPConvocation at AAFP Liberation and Great EnthusiasmLiberation and Great Enthusiasm Personalized Medical PracticesPersonalized Medical Practices Concierge Care for EveryoneConcierge Care for Everyone

Greenfield HealthGreenfield Health 9 FPs and IMs Practice in Portland, OR, 2 9 FPs and IMs Practice in Portland, OR, 2

officesoffices Chuck Kilo as Leader (IHI Experience)Chuck Kilo as Leader (IHI Experience) Interactive Website, Web Messaging, Interactive Website, Web Messaging,

Telephone and Selective Use of Office Telephone and Selective Use of Office VisitsVisits

Physician Spends Half Day Seeing Patients Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer– Visits 30 Minutes or Longer

Half Day MessagingHalf Day Messaging Volume is 20% Visits, 40% Telephone, 40% Volume is 20% Visits, 40% Telephone, 40%

Web MessagingWeb Messaging Annual fees range from $195 to $495 Annual fees range from $195 to $495

depending on agedepending on age

Kaiser Kaiser Permanente Permanente

HealthConnectHealthConnect24 Hour Access to 24 Hour Access to

Accurate and Accurate and Comprehensive Health Comprehensive Health Care Information and Care Information and

ServicesServices

Health Partners Online Health Partners Online User GrowthUser Growth

0

10000

20000

30000

40000

Mar

-04

Jun-

04

Sep

-04

Dec

-04

Mar

-05

Jun-

05

Sep

-05

Dec

-05

Mar

-06

Jun-

06

37,776

MyChart active usersMyChart active users

Health Partners Secure Health Partners Secure Messaging Messaging

Initial ObservationsInitial Observations Slow trickle at startSlow trickle at start Pioneering MDs with online Pioneering MDs with online

experience helped raise experience helped raise confidence and allay fearsconfidence and allay fears

Patient adoption dependent on Patient adoption dependent on local promotionlocal promotion

New Models of Care New Models of Care OnlineOnline

eDocAmerica – for patients eDocAmerica – for patients who use it, 24% of the time who use it, 24% of the time office visits are preventedoffice visits are prevented

Hawaii Health Care OnlineHawaii Health Care Online

Birth Announcement: Google, Microsoft, & Dossia Createthe Personal Health Information Network

Healthcare InformaticsHealthcare InformaticsApril 17, 2008April 17, 2008

Relationship Relationship Centered CareCentered Care

What is the 21What is the 21stst Century Century

Application?Application?

Substance is enduring, form is ephemeral. Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two Failure to distinguish clearly between the two is ruinous. is ruinous.

Success follows those adept at preserving Success follows those adept at preserving the substance of the past by clothing it in the substance of the past by clothing it in the forms of the future. the forms of the future.

Preserve substance; modify form; Preserve substance; modify form; know the difference.know the difference.

Wise Words from Dee Wise Words from Dee HockHock

Change Is Disturbing Change Is Disturbing When It Is Done To Us. When It Is Done To Us. Change Is Exhilarating Change Is Exhilarating When It Is Done By UsWhen It Is Done By Us

Rosabeth KantorRosabeth KantorHarvard Business Harvard Business

SchoolSchool

Human Nature Changes Human Nature Changes LittleLittle

Caring Remains PrimaryCaring Remains Primary

What Changes Are The What Changes Are The Tools And Methods We UseTools And Methods We Use