Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations

7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations

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S p o n S o r e d b y :

The Commowealth Fud

Dartmouth Ititute for Health Policyad Cliical Practice

Patiet-Cetered PrimaryCare Collaborative

This report was written and produced by Health2 Resources with funding provided by the Milbank Memorial Fund

Better toBestValue-Drivi Elemet of the Patiet Cetered Medical Homead Accoutable Care OraizatioM A R C H 2 0 1 1 W A s H I n g T O n , D . C .


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Contents

Acknowledgments 2

Meeting Attendees 4

Planning Committee 6

Letter from Donald M. Berwick, MD, Administrator,

Centers for Medicare & Medicaid Services 7

Preface 8

Introduction10

Enhanced Access to Medical Homes and Implications for ACOs 13

Discussion and Action Items 17

Better Care Coordination 20Discussion and Action Items 26

Better Health IT 28


Payment Reform for Primary Care Services 35


Closing Discussion, Group Consensus and Action Items 41


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A s the patient centered medical home expandsits reach in dozens o demonstration and pilotprograms nationwide, much attention has been

paid to its proven worth in well-known models,measured in improved outcomes and lowered

costs. But a number o questions remain as to the

medical homes value as it is applied more broadly.

Will a ocus on the value-driving elements o the

medical homecare coordination, access, new

payment models that reward positive outcomes,

and the meaningul use o health ITenable its

more rapid expansion and greater return on

investment? And what will be the role o the medi-

cal home as accountable care organizations enter

the marketplace, spurred by rewards promised in

the Patient Protection and Aordable Care Act?How can health care leaders plan now to frmly

establish the medical home within the greater

medical neighborhood o the ACO?

These questions spurred a meeting o the minds

o the leadership o health plans, business member-

ship organizations, consumer groups, academia,

ederal health entities and policymakers as they

met September 8, 2010 or a high-level, invitation-

only discussion about transorming health care.

Hosted by the Patient-Centered Primary Care

Collaborative (PCPCC) and sponsored by TheCommonwealth Fund and the Dartmouth Institute

or Health Policy and Clinical Practice, the one-day

Consensus Meeting ostered rank dialogue and

robust discussion. By the end o the day, this group

o accomplished and nationally recognized busi-

ness, health care industry and thought leaders sat

shoulder-to-shoulder in a powerul demonstration o

solidarity to see the medical home and ACOs work

to support the Triple Aim: Better care or individuals;

better health or the community; and reduce,

or at least control, the per capita cost o care.

This document is a result o that meeting, and is

intended to activate participants and the broader

health care transormation audience to pursue

the recommendations and action items brought

orward to eect needed change. We would like

to thank Katherine H. Capps and her colleagues

at Health2 Resources who led the planning com-

mittee, managed and produced the meeting,

invited speakers and participants and produced

this document.

For their contributions at the Consensus Meeting,we would frst like to thank Don Berwick, MD, head

o the Centers or Medicare & Medicaid Services,

or providing inspiration and a ramework to reach

consensus. We are also grateul to our moderator,

Susan Denzter, or her gracious and inormed

leadership, and to Diane R. Rittenhouse, MD, M.P. H.,

or writing the oreword. Much gratitude is also

extended to the subject matter experts who con-

tributed the topic research papers that served as

the background reading in preparation or the

meeting, and to the presenters who crystallized key

topic points and kicked o discussion around eachtopic. This was an amazing collaborative eort,

and we are grateul to those who oered their

time and expertise; the names o the presenters

and contributors are listed at the right.

Thanks also are extended to our report sponsor,

Milbank Memorial Fund, and or the contributions

that made this report possible.

Acknowledgments

Paul Grundy, MD, M.P. H.,PCPCC President, and IBMsGlobal Director o HealthcareTransormation

Elliott S. Fisher, MD, M.P. H., Director,Center or Population Health,Dartmouth Institute or Health Policyand Clinical Practice

Karen Davis, Ph.D., President,The Commonwealth Fund


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AccessPresenter:

Karen Davis,Ph.D., president,The Commonwealth Fund

Briefing document authors:

Melinda Abrams, MS, vice president,The Commonwealth Fund

Georgette Lawlor, program associate orpatient-centered coordinated care,The Commonwealth Fund

Steve Schoenbaum,MD, M.P. H., executive vicepresident or programs, The Commonwealth Fund

Karen Davis,Ph.D.,president,The Commonwealth Fund

Care CoordinationPresenters:

Elliott S. Fisher, MD, M.P. H., Director, Center orPopulation Health, Dartmouth Institute or HealthPolicy and Clinical Practice

Kevin Grumbach, MD, Professor and Chair, University

of California, San Francisco, Department of Family

and Community Medicine; Chief, Family and

Community Medicine, San Francisco General Hospital


David Meyers, MD, Director, Center or Primary Care,Prevention and Clinical Partnership, Agency orHealthcare Research and Quality

Debbie Peikes, Senior Researcher, MathematicaPolicy Research

Janice L. Genevro,Ph.D., M.S.W, Lead, Primary CareImplementation Team, Center or Primary Care,Prevention and Clinical Partnership, Agency orHealthcare Research and Quality

Greg Peterson, Researcher,Mathematica Policy Research

Tim Lake, Researcher, Mathematica Policy Research

Kim Smith, Researcher, Mathematica PolicyResearch

Erin Taylor, Associate Director, health research,Mathematica Policy Research

Kevin Grumbach, MD, Professor and Chair, University

of California, San Francisco, Department of Family

and Community Medicine; Chief, Family and

Community Medicine, San Francisco General Hospital

Health ITPresenter:

David K. Nace, MD, Vice President and MedicalDirector, McKesson Corporation and member othe PCPCC board o directors

Briefing document authors:John E. Jenrette, MD, Chie Executive and MedicalOfcer, Sharp Community Medical Group

David K. Nace, MD, Vice President and MedicalDirector, McKesson Corporation

Adrienne White, M.B.A., B.S.M.T., A.S.C.P., ManagingConsultant, IBM Global Business Services, Healthcare-Practice Business Analytics and Optimization,IBM Corporation

Payment ReormPresenters:

Allan H. Goroll, MD, Proessor o Medicine, HarvardMedical School; Chair, Massachusetts Coalition orPrimary Care Reorm

Diane R. Rittenhouse, MD, M.P. H., Associate Proessor,Department o Family and Community Medicineand Philip R. Lee Institute or Health Policy Studies,University o Caliornia, San Francisco


Thomas Bodenheimer, MD, Proessor in FamilyMedicine, University o Caliornia, San Francisco

Allan H. Goroll, MD, Proessor o Medicine, HarvardMedical School; Chair, Massachusetts Coalition orPrimary Care Reorm

Diane R. Rittenhouse, MD, M.P. H., Associate Proessor,Department o Family and Community Medicineand Philip R. Lee Institute or Health Policy Studies,University o Caliornia, San Francisco

Shawn Martin, Director o Government Relations,American Osteopathic Association


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Christine Bechtel,Vice President,National Partnership or Women and Families

Donald Berwick, MD, M.P.P., Administrator,Centers or Medicare & Medicaid Services

Katherine H. Capps, President, Health2 Resources,Planning Committee Chair*

Blair G. Childs, Senior Vice President, Premier, Inc.

Carolyn M. Clancy, MD, Director, Agency orHealthcare Research and Quality

John B. Crosby, JD, Executive Director,

American Osteopathic Association

Gerald Cross, MD, F.A.A.F.P., Acting Under Secretaryor Health, Veterans Health Administration

Helen Darling, President, National Business Groupon Health

Karen Davis, Ph.D., President,The Commonwealth Fund

Susan Dentzer, Editor-in-Chie, Health Aairs

Allen Dobson Jr., MD, Vice President,Clinical Practice Development,Carolina Health Care System

Susan Edgman-Levitan, PA, Executive Director,John D. Stoeckle, Center or Primary CareInnovation, Massachusetts General Hospital

Elliott Fisher, MD, M.P. H., Director, Center orPopulation Health, Dartmouth Institute or HealthPolicy and Clinical Practice

Richard J. Gilfllan, MD, Director o PerormanceBased Payment Policy, Centers or Medicare &Medicaid Services

Allan H. Goroll, MD*, Proessor o Medicine,Harvard Medical School, Chair,Massachusetts Coalition or Primary Care Reorm,Massachusetts General Hospital

Kevin Grumbach, MD*, Professor and Chair, Universityof California, San Francisco, Department of Family and

Community Medicine; Chief, Family and CommunityMedicine, San Francisco General Hospital

Paul Grundy, MD, M.P. H.*, IBMs Global Directoro Healthcare Transormation; President, Patient-Centered Primary Care Collaborative

Bruce H. Hamory, MD, F.A.C.P., Executive VicePresident, Chie Medical Ofcer, Geisinger

Yael Harris, Ph.D., M.H.S., Director, Ofce oHealth IT and Quality, Health Research andService Administration

Douglas E. Henley, MD, F.A.A.F.P., Executive VicePresident and CEO, American Academy oFamily Physicians

Jim Hester, Ph.D., Director, Health Care ReormCommission, Vermont State Legislature

Sam Ho, MD, Senior Vice President and ChieMedical Ofcer, UnitedHealthcare

Christine Hunter, Rear Admiral, Deputy Director,

The TRICARE Management Activity,U.S. Department o Deense

John E. Jenrette, MD*, Chie Executive and MedicalOfcer, Sharp Community Medical Group

Peter V. Lee, JD, Director o Delivery System Reorm,Ofce o Health Reorm, U.S. Department o Health& Human Services

Kevin E. Loton, F. A.C.H.E., President and CEO,Catholic Health System

Chris McSwain, Director o Global Benefts,Whirlpool

Steven Morgenstern, Benefts Manager,Dow Chemical Company

Albert Mulley, M.P. P., MD, Chie o the GeneralMedicine Division, Director o the Medical PracticesEvaluation Center, Massachusetts General Hospital

Meeting Attendees

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David K. Nace, MD*, Vice President and MedicalDirector, McKesson Corporation

Monique Nadeau, Executive Director,Hope Street Group

Patricia M. Nazemetz, Vice President and ChieEthics Ofcer, Xerox

Karen J. Nicholas, DO, MA, M.A.C.O.I., President,American Osteopathic Association

Carmen Hooker Odom, M.R.P.,President, Milbank Memorial Fund

Richard Popiel, MD, M.B.A., Vice President andChie Medical Ofcer, Horizon Blue Cross BlueShield o New Jersey

Kyu Rhee, MD, M.P.P., F.A.A.P., F.A.C.P., Chie PublicHealth Ofcer, Health Research and ServiceAdministration

Michael Rosenblatt, MD, Executive Vice President,Chie Medical Ofcer, Merck & Co., Inc.

Edwina Rogers, JD*, Executive Director,Patient-Centered Primary Care Collaborative

Lewis G. Sandy, MD, Senior Vice President,Clinical Advancement, UnitedHealth Group

Martin J. Sepulveda, MD, F.A.C.P., Vice President,Health and Well-Being, IBM Corporation

Michael S. Sherman, MD, M.B.A, MS, C.P.E, F.A.C.P.E.,Corporate Medical Director, Humana ClinicalGuidance Organization, Humana Inc.

Michael Suesserman, Vice President,

Corporate and Government Customers, Pfzer Inc.

Fan Tait, MD, F.A.A.P.*, Associate Executive Director,Director, Department o Community,Specialty Pediatrics, American Academyo Pediatrics

George E. Thibault, MD, CEO, Macy Foundation

John Tooker, MD, M.B.A., F.A.C.P.,Executive Vice President, Chie Executive Ofcer,

American College o Physicians

Jan Towers, Ph.D., NP-C, C.R.N.P., F.A. A.N.P.,Director o Health Policy, American Academyo Nurse Practitioners

Andrew Webber, President and CEO,National Business Coalition on Health

*Indicates the individual also served on the Planning Committee.


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Planning Committee

Melinda K. Abrams, MS, Vice President,The Commonwealth Fund

Thomas Bodenheimer, MD, M.P. H., Proessor,Department o FamilyandCommunity Medicine,University o Caliornia, San Francisco

Andrea Cotter, Director, Global Healthcare and LieSciences Marketing, IBM Corporation

Michael Dinneen, MD, Director, Ofce o StrategicManagement, U.S. Department o Deense

Robert Dribbon, Director, Health Care Strategy,Merck & Co., Inc.

Robert Dohert, Senior Vice President,Governmental Aairs and Public Policy,American College o Physicians

Janice L. Genevro, Ph.D., M.S.W.,Lead, Primary Care Implementation Team,

Center or Primary Care, PreventionandClinicalPartnership, Agency or Healthcare Researchand Quality

Martin Kohn, MS, MD, FACEP, FACPE, Associate

Director, Healthcare Analytics, IBM Research

Shawn Martin, Director o Government Relations,American Osteopathic Association

Karen Matsoka, D.Phil, M.Phil, Research Director,Engelberg Center or Health Care Reorm,Brookings Institute

David Meers, MD, Director, Center or Primary Care,PreventionandClinical Partnership,Agency or Healthcare Research and Quality

Kate Nehasen, MD, R-3, Resident Physician,Department o Family and Community Medicine,UCSF/San Francisco General Hospital

Dane C. Ptnam, Director, Employers Coalitions,Pfzer Inc.

Diane R. Rittenhose, MD, M.P. H., Associate Proessor,Department o Family and Community Medicine

andPhilip R. Lee Institute or Health Policy Studies,University o Caliornia, San Francisco

Rosemarie Sweene, Vice President,Public Policy and Practice Support,American Academy o Family Physicians

Adrienne White, M.B.A., B.S.M.T., A.S.C.P.,Managing Consultant, IBM Global Business Services,Healthcare Practice, Business Analytics andOptimization, IBM Corporation

Mark Zezza, Ph.D., Research Director,Engelberg Center or Health Care Reorm,Brookings Institute

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Dear Colleagues:As you may know, the topic o patient-centered care is dear to my heart. I believethat, o the

six IOM Aims or Improvementsaety, eectiveness, patient-centeredness, timeliness, eciency,and equitypatient-centeredness is the keystone and that, rom it, the others properly devolve.

To me, patient-centered care is care that respects each person as an individual, honoring his

or her backgrounds, their amilies and their choices.

The Aordable Care Act calls or investments in patient-centered care, including medical and

health homes and accountable care organizations (ACOs) so patients can receive seamless,

integrated care. At the Centers or Medicare and Medicaid Services (CMS), we intend to build on

the current oundation o medical and health homes and optimize their scope o services, capacity

and capabilities or patients. We will be working to incorporate patient-centered medical homes

with ACOs and examining various payment methods to support medical home expansion through

the CMS Center or Medicare and Medicaid Innovation (Innovation Center). Along with health

homes and ACOs, the Innovation Center will be tasked with evaluating the eect o the advancedprimary care practice model, commonly reerred to as the patient-centered medical home,

in improving care, promoting health, and reducing the cost o care provided to Medicare

beneciaries served by Federally Qualied Health Centers.

One thing is or surewe cannot do this alone. It is only through partnership with the private

sector that we will accomplish our aims or integrating care. We look orward to working

with you in the uture.

Sincerely,

Donald M. Berwick, MD

Administrator

Centers or Medicare and Medicaid Services


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What do you want health care to become?was the question that opened discussionamong a group o national thought leaders as-sembled on Sept. 8, 2010 in Washington, D.C. The

answer to this question became the ramework or

a daylong discussion led by moderator Susan

Dentzer and hosted by The Commonwealth Fund,

the Patient-Centered Primary Care Collaborative

and the Dartmouth Institute.

Almost eight months in planning, the journey to

the September 8 meeting began during a conver-

sation between Paul Grundy, MD, and White Househealth reorm policy sta during a roundtable

discussion on Aug. 10, 2009. The meeting show-

cased the evidence and outcomes1 rom patient-

centered models o care that are transorming

health care delivery. Those assembled recognized

that activity around the patient centered medical

home should ocus not only on the Joint Principles,

but on value-driving elements that would bring

about long-term, sustainable changes, with primary

care as a oundation. As a ollow up to that meet-

ing, the PCPCC brought in Health2 Resources,

which ormed a planning committee to oera structure, outline an approach and manage

a consensus meeting o engaged stakeholders.

Funding to support the eort was secured rom

Pzer, and Paul Grundy invited The Commonwealth

Fund and Dartmouth to serve as co-sponsors.

On May 4, 2010, Health Aairsheld a brieng at the

National Press Club to introduce its special issue,

Reinventing Primary Care. The issue was entirely

devoted to the topic o advanced primary care

models, making important links about value-driving

elements o the medical home and the role o

primary care within accountable care organiza-

tions. Recognition among thought leadership came

quickly that the medical home must operate in the

1 These outcomes are summarized in the PCPCC document,

Outcomes o Implementing Patient Centered Medical Home

Interventions: A Review o the Evidence rom Prospective EvaluationStudies in the United States. http://www.pcpcc.net/content/pcmh-

outcome-evidence-quality.

greater context o ACOsthe medical home situ-ated and unctioning within a medical neighbor-

hood. As CMS moved orward with its new charge

to rapidly advance promising primary care-based

models, it became clear that those supporting

primary care must also move orward to create a

consensus around key principles in this new context

Working rom a set o clearly enunciated goals, a

planning committee o thought leaders, researchers,

academics and ederal health agency leadership

began meeting weekly or what became known

as the September 8 Consensus Meeting. The desire

o the group was to build a broad consensus on

the oundation established by the Joint Principles

o the medical home, but to bring them to action

so consensus points can be used to create value

or those who purchase health care and or those

who deliver it within accountable care organizations

The patient centered medical home is an approach

to providing comprehensive primary care that

acilitates partnerships between individual patients

and their personal physicians and, when appropriate

the patients amily. ACOs, value-based insurance

design and multi-payer patient centered medical

home demonstrations must synchronize their eorts

in order to create a sustainable, long-term solution

to health care cost, quality, accountability and

access issues.

Preace

The desire o the group was to build

a broad consensus on the oundationestablished by the Joint Principles o

the medical home, but to bring them to

action so consensus points can be used

to create value or those who purchase

health care and or those who deliver it

within accountable care organizations.


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Each week during an hour-long call, the planningcommittee convened and discussed progress

toward the meeting. A host o academic and key

thought leaders spent many volunteer hours to

develop background papers that illuminated each

o the our value-driving topic areas the group

agreed to explore in detail, within the ramework

o developing consensus and action steps to drive

them orward within medical homes and ACOs:

Better care coordination1.

Better access to care (access as it relates2.to time, location, availability, etc.)

Better technology (patient portals, online3.

access to clinicians, health IT or quality

measurement)

Better payment models (designed to4.

achieve accountable, high quality,

patient-centered care)

Susan Dentzer, editor-in-chie o Health Aairs, wasinvited to serve as meeting moderator, and she

generously volunteered her time to the eort. We

also asked Dr. Donald Berwick, administrator o the

Centers or Medicare & Medicaid Services, to

discuss a vision or patient-centered care.

We are grateul or the signicant work o Susan

Dentzer and the planning committee members

as they conducted research, developed the

papers and presentations, brieed participants

prior to the meeting, and worked to activate

and engage ederal agency partnerships

around the meetings goals.

And nally, we are most thankul to PCPCC

President Paul Grundy, MD, whose sustaining

energy has sparked all our imaginations.

The initial goal to involve 35 national thought leaders

morphed to nearly 50 seated around the consensus

table on September 8, with additional sta and

planning committee members in attendance verymuch lling the room. Interest in the meeting topics

accelerated over the months o planning; it was

so overwhelming that we were orced to limit the

number o attendees to ensure robust discussion.

At the end o the day, we all let the September 8

Consensus Meeting sharing Don Berwicks passion

or the need to buy journeys, recognizing that the

value o the trip is entirely based on our own invest-

ment in it. The who, what, where and how state-

ments we use to populate the coming journey is

work still ahead o us. This document is a rst stepin drawing the roadmap we will use to navigate

that journey around policy, practice and research.

The broad set o consensus agreements and the

specic recommendations outlined over the course

o the meeting are presented here as action items

so they do not sit on a shel and become mere

mementos o the trip. There are research and

evaluation goals to be pursued, policies to be

championed, and models to be tested and

disseminated. The next leg o the journey

begins today.

Katherine H. Capps

President, Health2 Resources

Planning Committee Chair


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Introduction

The U.S. health care system is in crisis. Healthcare spending in the U.S. dwars that o otherindustrialized nations and threatens our ragileeconomy. The Institute o Medicine highlights the

chasm between the quality o care we receive

and the quality we should expect. Millions o

Americans have no health insurance, and the

rolls o the uninsured are rapidly expanding.

The ederal Aordable Care Act (ACA), passed

in March 2010, was a herculean attempt not only

to expand and reorm health insurance, but also to

drive quality improvements and decrease spending

in health care. It is not surprising that the processthat led to its passage was tumultuous. Health care

is not only a massive industry consuming roughly 17

percent o our gross domestic product, but it is also

deeply personal. Every person wants to be assured

that they will have easy access to the care they

need, when they need it, rom a team o providers

dedicated to maximizing their health and well-

being. Meanwhile, as a society, we must nd a

way to increase the value o health carebetter

access and quality at lower costsand this will not

be accomplished by tinkering around the edges.

A major overhaul is required. The health carereorm debate over the past many months has

been at once reasonable, rational, emotional

and divisive.

Truly remarkable was the emergence rom the tumult

o two widely endorsed models o delivery system

reorm: the patient centered medical home and the

accountable care organization. These models, taken

together, hold promise to alter the course o the U.S.

health care system. This report provides action items

to propel these initiatives orward.

The patient centered medical home (PCMH)

emphasizes the central role o primary care and

care coordination, with the vision that every person

should have the opportunity to easily access high

quality primary care in a place that is amiliar and

knowledgeable about their health care needs and

choices. The accountable care organization (ACO),

also coined the medical neighborhood, empha-

sizes the urgent need to think beyond patients to

populations, providing a vision or increasedaccountability or perormance and spending

across the health care system.

Embodied in the ACO and PCMH is a shared vision

or high-value health care in the U.S. The bipartisan

support or inclusion in the ACA refects a consensus

that the system is broken and something can,

and must, be done to x it. The models build on

decades o research and experience in a variety

o practice settings and communities. Neither

model dictates an ideal size or type o organiza-

tional setting, and it is not yet known exactly howthe models should be operationalized in any

particular setting.

But time and tide wait or no man.

Implementation is well underway, supported by a

broad-based coalition o health care stakeholders

rom the public and private sectors. Evaluations

o early initiatives demonstrate improvements in

health outcomes and patient experience, with

decreases in total expenditures. A new Center

or Medicare & Medicaid Innovation has beenestablished and charged with implementing ACO

and PCMH demonstration projects. The Oce o

the National Coordinator or Health Inormation

Technology, through the HITECH Act, has issued

Meaningul Use criteria and has dedicated money

to states and communities or implementation o

health inormation technology aimed at improving

population health outcomes. State governments

are experimenting with the models, with an eye

Every U.S. community can beneft

rom expanded access and improvedcare coordination spurred by health

inormation technology and paymentreorms. The question is where and

how to begin.


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toward preparing the delivery system or plannedMedicaid expansions. Private health care ounda-

tions are supporting community-based demonstra-

tions and evaluations to urther our collective

knowledge base. All the major national health

plans have PCMH demonstrations underway, and

the ederal government has adopted the PCMH

model within the Department o Deense and the

Veterans Administration. A large ederal demonstra-

tion project is targeting PCMH implementation in

ederally qualied health centers. Large and small

physician practices across the country are looking

or guidance on what these models mean orthem, and where and when to begin the process

o transormation.

This report presents action items or moving orward.

The product o multi-disciplinary discussion and lively

debate, the report delves beyond the boundaries

o specic delivery system models and addresses

undamental themes essential to improving care

and stemming rising costs. It presents recommenda-

tions or immediate action by stakeholders ranging

rom policymakers to providers and researchers.

The themes, or value-driving elements, that are

the ocus o this report are access, care coordina-

tion, health inormation technology and payment

reorm. The rst two are elements o health care

delivery that require urgent overhaul to maximize

health outcomes at lower costs. The latter two are

essential tools, without which widespread imple-

mentation o new care delivery models will not

succeed. These are not the only elements o our

current health care system that require attention,

but progress in each o these areas is necessary to

optimize value in health care. Every U.S. community

can benet rom expanded access and improved

care coordination spurred by health inormation

technology and payment reorms. The question is

where and how to begin.

Enhanced Access and Care Coordination

Enhancing access means increasing access

to health care in ways that add value by

improving both the quality and eciency ocare delivery. Care coordination is aimed at

improving the transer o patient care inorma-

tion, and establishing accountability by clearly

delineating who is responsible or which aspect

o patient care delivery and communication

across the care continuum. There is substantial

evidence that enhanced access and im-

proved care coordination result in improved

health outcomes and patient satisaction,

and decreased total costs o care or a

dened population.2

The presentations highlighted specic actions to

enhance access that have been shown to add

value, including o-hours access to primary care

to decrease reliance on the emergency depart-

ment; access to same-day or next-day primary

care appointments; access to appointments with

a personal clinician who is amiliar and knowl-

edgeable about the patient and his or her needs

and preerences; expanded modes o communi-

cation between patients and providers, including

advice lines, telephone appointments, electronic

visits and interactive websites; and special atten-tion to the needs o vulnerable patient popula-

tions who may ace time constraints, language

barriers or problems with transportation. Specic

actions that dene care coordination were also

discussed, including regularly assessing care

coordination needs; creating and updating

a proactive plan o care; emphasizing communi-

cation; acilitating transitions; connecting with

community resources; and aligning resources

with population needs.

Enhanced access and care coordination are

included in the core principles o the PCMH

model, and both are essential to the success o

any ACO that aims to improve health outcomes

2 Grumbach, K. and Grundy, Paul. Outcomes o Implementing

Patient Centered Medical Home Interventions: A Review o the Evidence

rom Prospective Evaluation Studies in the United States. Patient-Centered Primary Care Collaborative 2010. Accessed at http://www.

pcpcc.net/content/pcmh-outcome-evidence-quality.


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or a dened population at lower total costs.

This report summarizes the evidence base be-

hind enhanced access and care coordination;

describes the implementation opportunities

and challenges or both PCMHs and ACOs;and presents action items to begin to answer

important questions such as: What is the role

o primary care teams in enhanced access

and care coordination? and How can incen-

tives be aligned to drive excellence in access

and care coordination across all aspects o

the health care system?

Inormation Technology andPayment Reorm

Transormation o the U.S. health care systemto deliver greater value could be stimulated

by rapid advancements in two areas: wide-

spread implementation o health inormation

technology, and undamental reorm o the

payment system or primary care services.

While neither alone is sucient, both are

necessary to catalyze major delivery system

reorm. Electronic tools can acilitate, or

example, secure messaging, reerral manage-

ment, shared decision support, and peror-

mance reporting, the presenters explained.

Payment reorms can create nancial incen-tives to, or example, improve care coordina-

tion across settings; implement electronic visits

and expand ater-hours primary care access;

and minimize inappropriate use o costly

interventions. This report provides a review o

the challenges and opportunities or progress

in health IT implementation and payment

reorm; their relevance to the success o

PCMHs and ACOs; and action items to

acilitate progress in these areas.

The PCMH and ACO models incorporate the best

evidence and the best ideas to drive value in the

health care system. But the orward momentum

propelling these models cannot be explained by

new ideas or new evidence alone. What is historic

is the magnitude o the collaboration, the broad

inclusion o a wide variety o stakeholders, and the

diverse and dedicated leadership that spans the

private and public sectors and hails rom every

corner o the health care sector. Much o this

success can be attributed to the hard work by

leaders at the Patient-Centered Primary Care

Collaborative, the Dartmouth Institute, and The

Commonwealth Fund. Bravo or putting us all in

a room together and challenging us to communi-cate across traditional boundaries, to innovate,

investigate and leadalways keeping the patient

at the center. Responsibility or achieving greater

value in health care belongs to all o us. The action

items agreed upon at the September 8 Consensus

Meeting and detailed in this report provide much

needed direction. The time to act is now.

Diane R. Rittenhose, MD, M.P.H.

Associate Proessor

Department o Family and CommunityMedicine and Philip R. Lee Institute or

Health Policy Studies

University o Caliornia, San Francisco

November 2010


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Creating Value: EnhancedAccess to Medical Homesand Implications for ACOs

p r e s e n t e d b y

Karen Davis, Ph.D.,

president,

The Commonwealth Fund

Value Driving Elementsof Health Reform

This paper summarizes a brie prepared by Melinda K. Abrams, MS,

and a team at The Commonwealth Fund 3

Karen Davis, Ph.D., opened the Access topicsession with the observation that the goals othe Triple Aim (improved health or the population,

improved care or the patient and reducing the

per capita cost o care) are served by advancing

access to needed health care delivery. Quoting

PCPCC President Paul Grundy, MD, Davis pointed

out that there is consensus on what shouldhappenwith patient access to care, but there is a shortall in

executing the actions needed to makeit happen.

Seventy-three percent o Americans report having

diculty obtaining timely access to their doctor,

according to a 2008 Commonwealth Fund survey.

Access issues identied by those surveyed included

getting an appointment with a doctor the same or

next day when sick, without going to the ER; getting

advice rom the doctor by phone during regular

oce hours; and getting care on nights, weekends,

or holidays without going to the ER. Health insur-ance access issues, while important to our nations

overall health, are not included in this discussion o

access in patient centered medical home and

ACO models o care delivery.

Davis oered three answers to the question o

how to change problems with access:

1. We need to get out o denial about the

U.S. health system and realize there is a gap

between what we are achieving and what

is possible.

2. Incentives need to change (e.g., payment

reorm, transparency, public recognition).

3. We need the know-how about howto change.

3 M. K. Abrams, G. Lawlor, S. C. Schoenbaum, K. Davis, Creating

Value: The Importance o Enhanced Access to Medical Homes andWhat it Means or Accountable Care Organizations, The Commonwealth

Fund, orthcoming.

13


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PCMHs, ACOs and accessImproving patient access to primary care is central

to improving the quality and eciency o health

care. It can create greater value or patients,

providers and payers.

The evidence is consistently positive: When patients

have access to primary care, preventive services

increase, immunization rates improve, emergency

department visits and inpatient hospitalizations

decline and health care costs decrease.4,5

In the medical home, enhanced access to care

can include a variety o attributes; Davis discussed

six important ones:

1. Off-hours coverageWhen patients cannot reach or see their primary

care provider during o-hours, they tend to go to

the emergency department or seek an alternate

clinician, which can increase ragmentation and

4 J. M. Ferrante, B. A. Balasubramanian, S. V. Hudson, B. F.

Crabtree. Principles o the patient-centered medical home andpreventive services delivery,Ann Fam Med. Mar-Apr 2010;8(2):108-

16.

5 B. Starfeld, L. Shi, J. Macinko, Contribution o primary care to

health systems and health, Milbank Q,2005;83(3):457-502.

compromise quality o care. An estimated 40 to

50 percent o emergency department visits are

or non-urgent conditions, representing wasteul

health care expenditures.6 Davis relayed her

own story o sitting in an ER or hours becauseher doctor wasnt available.

When primary care providers have arrangements

or o-hours coverage, which is the expectation

o a medical home, the evidence shows reduct-

ions in emergency department use, increased

clinician satisaction and improvements in

patient experience.7, 8, 9

6 J. M. OConnell, J. L. Stanley, C. L. Malakar, Satisaction andpatient outcomes o a telephone-based nurse triage service, ManagCare, Jul 2001;10(7):55-6, 59-60, 65.

7 L. Huibers, P. Giesen, M. Wensing, R. Grol, Out-o-hours care in

western countries: assessment o dierent organizational models,

BMC Health Serv Res, Jun 2009, 23;9:105.

8 C. J. van Uden, R. A. Winkens, G. Wesseling, H. F. Fiolet, O.C. van

Schayck, The impact o a primary care physician cooperative on thecaseload o an emergency department: the Maastricht integrated

out-o-hours service, J Gen Intern Med, 2005 Jul;20(7):612-7.

9 S. Belman, V. Chandramouli, B. D. Schmitt, S. R. Poole, T. Hegarty

A. Kempe, An assessment o pediatric ater-hours telephone care:a 1-year experience,Arch Pediatr Adolesc Med, Feb

2005;159(2):145-9.

14

Source: Commonwealth Fund Survey o Public Views o the U.S. Health Care System, 2008.

Access Problems: Three o Four Adults Have DicultyGetting Timely Access to Their Doctor

30

73

60

41

Getting care on nights, weekends, orholidays without going to ER

Getting advice rom your doctor byphone during regular ofce hours

Getting an appointment with a doctor the sameor next day when sick, without going to ER

Any o the above

Percentage reporting that it is very difcult/difcult:

0 25 50 75 100


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O-hours coverage requires collaboration

among primary care providers. ACOs may be

able to take the lead, she said, but so ar, it

hasnt happened.

2. Same-day or next-day access

The Commonwealth Funds 2009 International

Health Policy Survey showed that one-th

o Americans report waiting six or more

days to obtain an appointment with their

primary care physician.10 Lack o timely access

to primary care can not only delay diagnosis

and treatment, but also signals a lack o

respect or patients concerns and time.

One strategy to reduce wait times or appoint-

ments is advanced access or open access.

Research suggests this approach candecrease appointment no-shows, improve

continuity o care and increase patient

and clinician satisaction.

Providing same-day or next-day appointment

scheduling requires a commitment to practice

redesign, and building the patients experi-

ence into the nancial reward system, Davis

said. That could involve explicitly tying

bonuses or value-based purchasing to

this type o access.

3. Appointments with a personal clinician

Ensuring the appointment is with the patients

personal clinician is a hallmark o continuity

o care and having a true medical home,

but only 65 percent o U.S. adults report

having an accessible personal clinician.11

When patients have access to (and continuity

with) their primary care provider, preventive

care screening rates are higher, immunization

rates are higher, emergency department

and hospital visits are ewer, health care

costs are lower and patient satisaction is

10 C. Schoen, A Survey o Primary Care Physicians in 11

Countries, 2009: Perspectives on Care, Costs, and Experiences,

2009.

11 The Commonwealth Fund Commission on a High

Perormance Health System, Why Not the Best? Results rom the

National Scorecard on U.S. Health System Perormance, 2008

(The Commonwealth Fund, July 2008).

Electronic Access to Care:Evidence Shows Improvements in Quality

Early studies suggest that electronic communication withproviders and patient access to medical records over the

Internet may improve doctor-patient communication andhelp patient sel-management

Group Health Cooperatives Access Initiative includedthe ollowing:

Secure email with MDsy

Medical record accessy

Medication refllsy

Appointment schedulingy

Discussion groups and health promotion inormationy

Results rom Group Healths Access Initiative:Patients reported better access to care (e.g., time toy

appointment, seeing personal doctor, getting needed care)

Providers reported improvements in quality o service giveny

to patients (pride in service provided)Surveys did not assess patient experience with securey

email communication or other Web services

J. D. Ralston, D. P. Martin, M. L. Anderson, P. A. Fishman, D. A. Conrad,E. B. Larson, D. Grembowski, Group health cooperatives transormation towardpatient-centered access, Med Care Res Rev, 2009 Dec;66(6):703-24.

Access to Medical Homes Reduces

Racial/Ethnic DisparitiesWhen racial and ethnic minorities have access to a medical

home, disparities in care are eliminated or substantially reduced

Access to care must accommodate needs o vulnerable

patient populations

For example, when limited English profciency patients seey

clinicians that speak the same language, they ask more

questions and report better clinical outcomes

When patients have proessional interpreters, instead o ady

hoc interpreters, they report better

communication (ewer errors, greater comprehension)

management o chronic disease

patient satisaction

ollow-up and adherence to clinical advice

A.C. Beal et al. Closing the Divide: How Medical Homes Promote Equity in HealthCare: Results From The Commonwealth Fund 2006 Health Care Quality Survey(The Commonwealth Fund, June 2007); A. C. Beal et al. Latino access to thepatient-centered medical home, J Gen Intern Med, 2009 Nov;24 Suppl3:514-20; Q. Ngo-Metzger et al. Providing high-quality care or limited Englishprofcient patients: the importance o language concordance and interpreter use,J Gen Intern Med, Nov 2007;22 Suppl 2:324-30; L. S. Karliner et al. DoProessional Interpreters Improve Clinical Care or Patients with Limited EnglishProfciency? A systematic Review o the Literature, Health Services Research,

April 2007,42:2.

15


18/4816

signicantly improved.12,13,14 Overall, continuity

o care with a personal clinician or care team

is associated with increased eciency and

better quality o care. In addition, providing

better, less expensive care or patients withchronic conditions is a high-yield approach

to more accountable care and the

success o ACOs.

We need to do everything we can to encourage

enrollment o patients with their patient centered

medical home, with their source o primary

care, Davis said. But ACO attribution, or assigning

a patient to a primary care provider, isnt enough

by itsel: There needs to be dialogue. Doctors

and patients need to talk to each other about

their mutual expectations and responsibilities.

4. Ability to have clinical questions answered

by telephone

Establishing dedicated telephone appointments

during oce hourswhen they are an appropriate

substitute or in-person carecan reduce patient

oce visit and costs without degrading medical

outcomes or patient satisaction.

Studies show that telephone appointments have

helped clinicians successully monitor patients

with depression, asthma and urinary tract inec-tions.15 A study o telephone care provided to

elderly men in a clinic operated by the Veterans

Health Administration showed 19 percent ewer

oce visits, 28 percent ewer hospital admissions

and shorter hospital stays, 41 percent ewer

12 A. G. Mainous, R. J. Koopman, J. M. Gill, R. Baker, W. S.

Pearson, Relationship between continuity o care and diabetes control:evidence rom the Third National Health and Nutrition Examination

Survey,Am J Public Health, 2004;94(1):66-70.

13 J. W. Saultz, W. Albedaiwi, Interpersonal continuity o care and

patient satisaction: a critical review,Ann Fam Med, 2004;2(5):44551; J. M. De Maeseneer, L. De Prins, C. Gosset, J. Heyerick, Provider

continuity in amily medicine: does it make a dierence or total health

care costs?Ann Fam Med, 2003;1(3):144-148.

14 M. J. Hollander, H. Kadlec, R. Hamdi, A.Tessaro, Increasing

Value or Money in the Canadian Healthcare System: New Findingson the Contribution o Primary Care Services, Healthcare Quarterly,2009;12(4):30-42.

15 L.L. Berry, Innovations in access to care: a patient-centered

approach, 2003.

intensive care unit days and 28 percent less

estimated total health care expenditures.16

Redesign care delivery to give physicians time in

their schedules to call patients, Davis suggested,and oer a reasonable nancial incentive to

encourage them to do it. By introducing a structure

or the activity and the reimbursement or it, we can

make the right thing to do the easy thing to do.

5. Electronic access to providers and services

Patients access to care can be vastly improved

through appropriate use o Web-based or online

health care services.

Although 58 percent o U.S. adults would like to

communicate with their physician by email, only21 percent report the ability to do so.17 But studies

suggest that electronic communication with provid

ers and patient access to medical records over the

Internet may improve doctor-patient communica-

tion and help patient sel-management.18 Patients

reported better access to care (e.g., time to ap-

pointment, seeing personal doctor, getting needed

care), and providers reported improvements in

quality o service given to patients.19

It saves time or everyone, and it lets patients and

amily members review the physicians recommen-dations at their leisure.

6. Access for vulnerable patient populations

Access to care must accommodate the needs o

vulnerable patient populations, and PCMHs appear

to help achieve this goal and make a dierence in

reducing disparities. For example, Davis pointed out

that when racial and ethnic minorities have access

to a medical home, disparities in care are eliminat-

ed or substantially reduced. I was really shocked at

16 J. Wasson, C. Gaudette, F. Whaley, A. Sauvigne, P. Baribeau, H.

G. Welch, Telephone care as a substitute or routine clinic ollow-up,

JAMA, 1992;267:1788-93.

17 S. K. H. How, Public Views on U.S. Health System Organization:

A Call or New Directions, 2008.

18 J. D. Ralston, D. P. Martin, M. L. Anderson, P. A. Fishman, D. A.Conrad, E. B. Larson, D. Grembowski, Group Health Cooperatives

transormation toward patient-centered access, Med Care Res Rev,2009 Dec;66(6):703-24.

19 ibid


19/4817

how much the racial and ethnic disparities in

access to care, quality o care, preventive care

were eliminated i you were given care in a prac-

tice that met the characteristics o the patient

centered medical home, she said.

For the promise o enhanced access to be realized

by all patients, including the medically underserved,

the strategies and methods applied will need to

be tailored to meet the needs o vulnerable

patient populations.

ACOs enabling enhanced access

ACOs need a strong oundation o primary care

to succeed. The patient centered medical home

is the oundation or everything that calls itsel anACO, Davis said. On that oundation, there can

be dierent models or ACOs: There are dierent

ways to build the neighborhood.

Medical home care coordination and care

management activities will enable the ACO

to realize cost savings. PCMHs can benet rom

ACO inrastructure and support (e.g., inormation

technology, data collection and reporting,

additional personnel) to help PCMHs meet

their unctional requirements.

ACOs can also enhance the elements o access

that medical homes cannot oer on their own:

ACO spport or o-hors coverage: Through

the inrastructure o an ACO, small practices

can be networked or organized to more

easily share personnel to provide ater-hours

care or their patients. Alternatively, hospital-

based sta that is part o the ACO or under

contract to it can provide telephone triage

and urgent care visit services or primary

care practices.

Facilitate online access, provide tech spport:

ACOs can deray the nancial and adminis-

trative investment to provide Web-based

services, such as electronic physician-patient

messaging, e-consultations and personal

health records. ACOs can set parameters o

how these systems can/should be organized

as well as provide the resources to monitor

whether patients access to care improves.

ACOs can help primary care sites collect,

analyze and report quality data to monitor

their perormance.

Improve access to specialt care services: In

an ACO, the complement o clinicians is held

accountable or the quality o care provided

to an entire population o patients. With such

shared responsibility, the PCMH, specialty care

providers and the ACO can work together to

set up systems and agreements to ensure

timely access to specialty care services.

ACOs and PCMHs need each other, Davis said.

The evidence demonstrates that when patients

have enhanced access to primary care services,quality, eciency and patient experience improve.

Discssion and action items

One overarching consensus item emerged early

on in discussion ater the initial presentation: Any

discussion on the application o the elements o the

PCMHwhether it be care coordination, access, use

o health IT or redesign o payment modelsmust

be ramed in the context o bothenhancing value

or the patient and bending the cost curve. Valueor the patient must be inormed by the consumer

voice. The group consensus was that these two

elements should stand as the ramework or action

going orward in all our discussion topic areas.

The discussion then ocused on what it takes within

the physician practice to provide enhanced

access. Primary care capacity is a real issue; train-

ing and project management support is needed to

help practices become high-access primary care

sites. Investments are being made now to increase

the primary care workorce, but it will take time or

the pipeline to bring those newly trained proession-

als to the eld.

The primary care workorce shortage is urther

complicated by dierences in scope-o-practice

laws across states. I each health care provider is

to work at the top o his or her license to enhance

access, clarity is needed regarding which practitio-

ner is allowed to perorm specic services.


20/4818

Policy Action item(s):

Actively support ederal unding o1.

primary care workorce training eorts

across the ull spectrum o primary care

team members in order to ensure an

adequate and well-trained primary

care workorce.

Policies and initiatives that promote2.

ACOs and PCMHs must incentivize

innovative delivery models that ensure

superb patient access to care including

o-hours coverage, same-day or next-

day visits, telephone and electronic

access, and access to electronic

medical records.

There was considerable discussion about the role

o health plans and hospitals in enhancing access.

These entities have resources already in place that

could support physician practices, such as nurse

call lines, telephonic case management and

disease management programs and ater-hours

urgent care acilities. However, patients continue to

experience problems in accessing care. Medical

home and ACO demonstration projects mustinclude collaboration between primary care

practices and hospitals and/or health plans to

test new ways to ensure enhanced access to

primary care or all patients. These eorts will inorm

the uture development o the medical neighbor-

hood, which will be critical to the success o the

ACO. This sort o attention to enhanced access

as part o existing medical home demonstrations

would require development o the medical neigh-

borhood that takes in providers (including special-

ists, hospitals and primary care providers), payers

and consumers as collaborative partners.

In particular, there is an opportunity to re-envision

the role o the hospitalspecifcally, or hospitals to

provide support o primary sites, but not through

their emergency departments, which are not

cost-eective delivery sites or primary care.

There was considerable discussion about the

consumer voice in access and a direct challenge

to include consumers in design o demonstration

projects. Incentives need to be aligned or consum-

ers to seek care in their primary care setting, rather

than turning to more costly avenues or care.

Cultural dierences also play a role in whereand how consumers seek care.

Demonstration Project Action Item(s):

1. Develop design principles to set up

systems to enable more efcient and

coordinated use o a communitys

existing access resources (e.g., call-in

lines, urgent care). Encourage collabo-

ration between health plans, hospitalsand primary care sites to reconfgure

existing resources in order to support

patients timely and appropriate

access to their patient centered

medical homes.

2. Develop a reimbursement ramework

o enhanced access that is both

patient-centered and low-costin the

ambulatory settings (whenever appro-

priate) and where it will best beneft

the patient.

3. Involve consumers in design o all

projects, but especially those that seek

to enhance access, since it is an issue

o paramount concern and interest to

patients. Keep in mind Davis directive

to make the right thing to do the easy

thing to do.

I primary care providers are to take on new access

pointstelephonic and online consultation and

ater-hours care among themmetrics and incen-

tives should be aligned to ensure that bettercare

is being delivered, not just morecare. There is an

essential need or unctional operational metrics

to understand what constitutes access. There

is urther need to refne metrics to identiy and

monitor appropriate vs. bad access.


21/4819

Once this ramework is determined, there is a need

to assign which caregivers constitute the access

team and to dene the role and unction or each

team member. Best practices in improved access

are in the eld, but the elements o access thatmake these practices successul need urther

analysis and documentation.

Research Action Item(s):

1. Set up a research/learning collaborative

to capture learnings on improving prima-

ry care bandwidth to expand access

and to cull lessons rom existing

demonstrations.

2. Identiy the ramework or access (what

needs to be done to achieve access),

and then move to the roles and unctions

o team members (who needs to do it).

3. Develop unctional operational metrics

or appropriate access.

Melinda Abrams, MS, Vice President,


Georgette Lawlor, Program Associate or

Patient-Centered Coordinated Care,


Steve Schoenbam, MD, M.P.H., Executive Vice

President or Programs, The Commonwealth Fund

Karen Davis, Ph.D., President,


PLANNING COMMITTEE CHAIR

Katherine H. Capps, President, Health2 Resources

The original Access briefng document or the Sept. 8, 2010 Consensus Meeting can beobtained rom The Commonwealth Fund and was prepared by:


22/48

Creating Vale:

Better Care Coordination

p r e s e n t e d b y

Elliott S. Fisher, MD, M.P.H.,director, Center or Population Health,Dartmouth Institute or Health Policy

Kevin Grmbach, MD,proessor and chair, UCSF Departmento Family and Community Medicine

Fisher and Grumbach credited davi M, Md, director,Center or Primary Care, Prevention and Clinical Partnership at

the Agency or Healthcare Research and Quality, orplaying a major role in the papers development.

20

Care coordination is the deliberate organization

o patient care activities between two or more

participants (including the patient) involved

in a patients care to acilitate the appropriate

delivery o health care services.20

The eective coordination o a patients healthcare services is a key component o high-quality,ecient care. It provides value to patients, proes-

sionals and the health care system by improving the

quality, appropriateness, timeliness and eciency o

decision-making and care activities, thereby aect-

ing the experience, quality and cost o health care.

But care coordination is largely missing rom the

status quo. And so Kevin Grumbach, MD, beganthe session on Care Coordination with a stark

but unsurprising assessment: The health care

system is ailing due to a lack o integrated,

coordinated care.

Care coordination has two key operational principles

he explained: the transer and exchange o inorma-

tion, and accountability. The ormer involves the

appropriate fow o inormationsuch as medical

history, medication lists, lab results, imaging studies

and patient preerencesrom one participant in a

patients care to another (including the patient).

The latter, accountability, requires clarity about the

responsibility o participants in a patients care or

each aspect o that care, e.g., speciying who is

primarily responsible or key care delivery activities,

the extent o that responsibility, and when that

responsibility will be transerred to other care partici-

pants. And it means engaging patients to develop

care plans that are accountable to the patient

and the care team.

20 McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Krat S,McKinnon M, Paguntalan H, Owens DK. Care coordination. Vol 7 o:

Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closingthe quality gap: A critical analysis o quality improvement strategies.

Technical Review 9 (Prepared by Stanord-UCSF Evidence-Based

Practice Center under contract No. 290-02-0017). AHRQ PublicationNo. 04(07)-0051-7. Rockville, MD: Agency or Healthcare Research

and Quality. June 2007.


23/48

Care coordination and primary careCare coordination is an essential component o

primary care. As conceptualized by the Institute

o Medicine, primary care consists o the provision

o accessible, comprehensive, longitudinal andcoordinated care in the context o amilies and

community.21 More simply, it is the our cardinal

Cs: rst contact, comprehensive, continuity

and coordination.

In this conceptual model, primary care serves a

critical integrating unction or the diverse services

a patient may need, promoting cohesive, whole-

person care.

The exceptional value primary care brings to health

care systems22 is due in part to the care coordination

provided by primary care proessionals and the

inormed decision-making it allows them to make.

Grumbach shared six central activities within care

coordination that enhance health care value that

were identied in the background paper:23

1. Assess patient needs. Care coordination needsare based upon a patients health care needs

and treatment recommendations, which refect

physical, psychological and social actors.

Coordination needs also are determined by

the patients lie circumstances, current healthand health history, unctional status, sel-

management knowledge and behaviors,

and need or support services.

2. Develop and update proactive plan of care.Establish and maintain a plan o care, jointly

created and managed by the patient/amily

and health care team. The plan outlines the

patients current and longstanding needs

and goals or care, and identies coordination

needs and potential gaps. It clearly identies

the roles o each participant in the patients

care. It anticipates routine needs and tracks

up-to-date progress toward patient goals.

3. Emphasize communication.Communicationmay take a number o orms (e.g., oral,

electronic, ace-to-ace, asynchronous), and

it occurs between health care proessionals

and patient/amily, within teams o health care

proessionals and across teams or settings.

4. Facilitate transitions. Share inormation amonproviders and patients when the accountabilit

or some aspect o a patients care is trans-

erred between two or more health care

entities. Transitions require transer o both

accountability and inormation.

5. Connect with community resources.Provideand, i necessary, coordinate services with

additional resources available in the commu-

nity that help support patients health and

wellness or meet their care goals.

6. Align resources with population needs.Use a systems-level approach within the

health care system to assess the needs o

populations and to identiy and address gaps

in services. Aggregating the needs assessment

conducted with individual patients is one

method that should be used to identiy the

overall populations needs. Care coordination

and eedback rom providers and patients

should also be used to identiy opportunities

or improvement.

23 Fisher, Elliott; Grumbach, Kevin; Meyers, David, et al. Unpublished,September 8, 2010 Consensus Meeting Briefng Materials on Care

Coordination: Issues or PCMHs and ACOs

21 Primary Care: Americas Health in a New Era. Washington, DC.:

National Academy o Sciences; 1996.

22 Starfeld, B., L. Shi, and J. Macinko. Contribution o Primary Care

to Health Systems and Health. The Milbank Quarterly, vol. 83, no. 5,2005, pp. 457502.

21

Value-enhancing activities


24/48

The integrative unctioninterpreting with patients

the meaning o many streams o inormation and

working with the patient to make decisions based

on the ullest understanding o this inormation in

the context o the patients values and preerencesis an under-recognized and under-appreciated

value o primary care. Primary care thus is integral

to coordination o care.2122,23

Finding a pathway through the

medical neighborhood

So where does the primary responsibility or these

care coordination activities lie? Some belong in

the medical home, some in the greater medical

neighborhoodthe extended health community

o specialists, hospitals and other providers.(This medical neighborhood may or may not

be a ormally constituted accountable

care organization.)

In an accompanying slide, Grumbach illustrated

how the activities can be acilitated within the

PCMH and greater medical neighborhood

(in this case, an ACO).24

23


Coordination: Issues or PCMHs and ACOs.

He also explained the synergistic relationship

between the neighborhood and the PCMH. There

has to be a centersome glue that holds it togeth-

er, he said, reerring to the need or the primary

care team and the patient to serve as the nucleuso care coordination.

The patient centered medical home is the center-

piece o the medical neighborhood, but its only

a piece. The medical home should be nested

within a well-unctioning medical neighborhood.

That neighborhood is an accountable system that

ensures everything that needs to happen does

indeed happen.

Patients oten need many services in addition to

primary carespecialists, home care, pharmacy,workplace, and more. It all has to t together, and

coordination is key to making this work, Grumbach

said. There is value in having care thats pulled

together and coordinated, with the patientand

ideally the medical homeat the center.

Reviewing the evidence

Research appears to support this approach to

care, as is detailed in the brieng document.25

(For a more detailed review o the research, see the

brieng documents appendix.) Recent compre-hensive eorts to strengthen primary care, including

implementation o the PCMH model by Group

Health Cooperative (which emphasized the core

coordination unctions o primary care), are dem-

onstrating improved patient experience, improved

sta experience, improved quality and reduced

emergency department and hospital utilization.26

Well-designed, targetedcare coordination inter-

ventions delivered to the right individual can

improve patient, provider and payer outcomes,

especially when embedded in or closely articu-

lated with the patient centered medical home.27

25 Fisher, Elliott; Grumbach, Kevin; Meyers, David, et al. UnpublishedSeptember 8, 2010 Consensus Meeting Briefng Materials on Care

Coordination: Issues or PCMHs and ACOs.

26 Reid, RJ et al. The Group Health Medical Home at Year Two: Cost

Savings, Higher Patient Satisaction, and Less Burnout or Providers

Health Aairs, 2010; (29(5):835-843.

27 Ibid.

22

Care Coordination Activities Determine and update care coordination needs

Create and update a proactive plan o care

Communicate:

Between health care proessionals & patients/amily

Within teams o health care proessionals

Across health care teams or settings

Facilitate transitions

Connect with community resources

Align resources with population needs ACO

pCMH


25/4823

For patients with chronic conditions, particularly

those at relatively high risk o poor outcomes,

what appears to work best, Grumbach and Fisher

suggested, is the inclusion o a designated person

oten a nurse or social workerwho plays a target-ed care coordination role.

Some targeted care coordination team-based

models have been shown to improve health out-

comes and/or reduce hospitalizations, readmissions

and/or costs. In the studies reviewed, hospitalization

rates dropped between 8 percent and 46 percent.28

All successul models o care coordination have

incorporated someor oten, more extensiveace-

to-ace interaction between patients and care

coordinators to establish and maintain personal

relationships. As reported in the backgrounddocument,29 almost all successul models o target-

ed care coordination have also incorporated some

ace-to-ace interaction between the designated

care coordinators and clinicians.

Not all care coordination programs have been

shown to be eective. For example, targeted care

coordination interventions have been shown to

be successul or high-risk/high-need patients.30,31

However, these services provided to low-risk

Medicare patients have not been shown to

improve the quality o care or utilization, andat times have increased overall costs.32,33

28 Ibid.

29 Ibid.

30 Peikes, Deborah, Arnold Chen, Jennier Schore, and Randall

Brown. Eects o Care Coordination on Hospitalization, Quality o Care,

and Health Care Expenditures Among Medicare Benefciaries: 15Randomized Trials. JAMA. 2009, vol. 301, no. 6: 603-618.

31

Peikes, Deborah, Greg Peterson, Jennier Schore, CarolRazafndrakoto, and Randall Brown. Eects o Care Coordination on

Hospitalization, Quality o Care, and Health Care Expenditures AmongMedicare Benefciaries: 11 Randomized Trials. Drat manuscript,

2010.

32 Counsell SR, Callahan CM, Clark DO, et al. Geriatric care

management or low-income seniors: a randomized controlled trial.

JAMA. 2007;12;298(22):2623-33.

33 Counsell, SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost

Analysis o the Geriatric Resources or Assessment and Care o EldersCare Management Intervention. Journal o the American GeriatricsSociety. 2009; 57(8): 1420-1426.

In addition, disease management services provided

primarily by telephone have not been shown to be

eective or Medicare beneciaries.34

Bridging the PCMH, ACO perspectives:

Integrated care

Care coordination is a core activity o the patient

centered medical home. Using proactive care

teams, primary care medical homes are able to

both coordinate care with and or patients, and

use the results o eective coordination to develop

appropriate care plans. For most patients in a

primary care practice, the medical home team

which might contain nurses, pharmacists, physicians,

medical assistants, educators, behavioralists, social

workers, care coordinators and otherstakes thelead in working with the patient to dene care

needs, and to develop and update a plan o care.

The PCMH team is also responsible or ensuring

communication with patients and amilies and

across the primary care team. The PCMHs responsi-

bility includes collaborating with proessionals and

teams in other settings that participate in a given

patients care, including at points o care transitions.

The PCMH should also be involved in connecting

with community resources and aligning

those resources.

For accountable care organizations, care

coordination is critical to achieving high-quality

and high-value care. Building upon the care

coordination eorts o PCMHs, ACOs can ensure

and incentivize communication among teams o

providers operating in varied settings. Additionally,

ACOs can acilitate transitions and align resources

to meet the clinical care and care coordination

needs o populations. This work includes, but

extends beyond, creating hospital discharge

care coordination programs, to creating a medical

neighborhood where providers share inormation

with one another. ACOs can ensure that the

appropriate transitions o accountability happen

and that specialty teams are ready, willing and

able to provide the requisite services. ACOs can

34 Esposito, D., J. Schore, R. Brown, A. Chen, R. Shapiro, A.

Bloomenthal, and L. Gaber. Evaluation o Medicare DiseaseManagement Programs: LieMasters Interim Report o Findings.

Princeton, NJ: Mathematica Policy Research, February 19, 2008.


26/4824

also develop and support systems or care

coordination or patients who reside in

non-ambulatory care settings.

A concept that bridges the PCMH and ACO per-spectives on care coordination is integrated care.

Integrated health care starts with good primary

care and reers to the delivery o comprehensive

health care services that are well coordinated with

good communication among providers; includes

inormed and involved patients; and leads to

high-quality, cost-eective care. At the center o

integrated health care delivery is a high-perorming

primary care provider who can serve as a medical

home or patients.35 As this denition indicates,

a well-unctioning primary care medical home

is a necessary component o integrated carebut, alone, it is not sucient. True integration also

requires a cohesive medical neighborhood.

Moving ahead: organizing principles

Elliott Fisher, MD, M.P.H., then identied what he and

Grumbachand the authors o the background

paper36consider the organizing principles or

care coordination in PCMHs and ACOs.

First, care coordination is an essential unction o

primary care and the PCMH. To be successul andsustainable, PCMHs require resources that enable

care coordination, including health IT and appropri-

ately trained sta or team-based models, as well

as payment models that compensate PCMHs or

the eort devoted to care coordination activities

that all outside the in-person patient visit.

All patients have care coordination needsand

benet rom receiving appropriate coordination,

but those with complex health needs probably

have the greatest need and benet the most.

Eective care coordination involves the ability to

meet the care coordination needs o all patients

through appropriate assessment, and ecient care

35 Aetna Foundation, Program Areas: Specifcs. 2010.

(Accessed 8/2/10, at http://www.aetna.com/about-aetna-insurance/aetna-oundation/aetna-grants/program-area-specifcs.html.)


Coordination: Issues or PCMHs and ACOs

coordination directs more intensive and personal-

ized services to those with the greatest needs.

Patients requiring complex care rom multiple

providers oten need enhanced coordination oservicesand these services may require the

support o skilled care coordinators who work

closely with patients, amilies and clinicians.

Evidence suggests that care coordinators should

be supported in having ace-to-ace contact with

patients to help build trust. Comprehensive care

coordinators can be integrated into PCMH primary

care teams. Coordinators who operate outside o

the PCMH oce should develop close and strong

relationships with the PCMH team. ACOs should

develop additional care coordination programs

or other settings, such as hospitals.

ACOs have the potential to improve care coordina-

tion by creating the contextto support medical

homes with a strong oundation in primary care.

ACOs can provide incentives and structures that

ensure coordination and cooperation across care

teams and settings, and they should be able

to align resources to meet population care

coordination needs.

Care coordination interventions, in both PCMHs

and ACOs, must be designed to refect thestrengths and needs o local communities.

Mltiple models are likel to emerge, and both

PCMHs and ACOs shold be evalated and the

reslts shared widel. Learning rom the experiences

in place about what works and what doesnt work

is crucial to multiplication o successul models.

Begin thinking about levers and metrics

Fisher then began the transition to the group

discussion with an action-oriented question:

As we think about the discussion and our work

o the day, what are the levers we can identiy

or public payers, private payers, participants in

the health care system?

He encouraged participants to think in terms o the

Triple Aim (improve the health o the population;

enhance the patient experience o care; and

reduce, or at least control, the per capita cost o


27/48

care) as the overarching goal, and care coordina-

tion as one o the activities that will help achieve

that goal.

In that context, there are multiple levers, he noted,including quality measurement levers, to let us

know i we are making a dierence, reimbursement

incentives to support enhanced care coordination,

and other policy levers such as regulatory issues,

workorce issues and o course, the research.

Metrics, too, are crucial, he said. Fisher briefy

discussed a National Quality Forum model that

looks at patients across the continuum o care

needs (at-risk, acute, post acute, etc.) and shows

where the system reaches in or out to the patient.

Perormance measurement or care coordination

is part o a larger NQF project or developing a

measurement ramework or evaluating eciency,

and ultimately value, across patient-ocused

episodes o care. The ramework could help identiy

critical gaps in quality measurement and serve as

a springboard or dening longitudinal perormance

metrics that include patient-level outcomes (e.g.,

health-related quality o lie, patient experiencewith care), resource use (e.g., quantity o services

provided to patients, true costs paid or each

service), and key processes o care (e.g., shared

decision making, patient engagement).37

It could, Fisher said, provide a oundation or

understanding whether the activities o the patient

centered medical home or an accountable care

organization are actually achieving the promise

that Don [Berwick] is asking us to step orward

and ocus on.

37 National Quality Forum: Measurement Framework: EvaluatingEfciency Across Patient-Focused Episodes o Care; http://www.

qualityorum.org/Projects/Episodes_o_Care_Framework.aspx

25

Measres o coordination: Goals of care met Care transitions managed Care plans aligned

Staing Health Getting Better Living w/Illness/Disabilit

At Risk Acte Rehab RecoverCare

Onset

pHAse 1

pHAse 2 pHAse 4pHAse 3

ActePhase

Post Acte/Rehabilitation

Phase

20

Prevention

Risks reduced

Good unction

Great care

Minimal cost

Performance Measurement:NQF Episode Measurement Framework


28/48

Discssion and action items

Once again, the discussion ocused on the need to

set a ramework or discussion that emphasizes both

enhanced value or the patient and the need to

eectively bend the cost curve. Value or the

patient must be inormed by the consumer voice,

and an eye must also be kept on cost containment.

On the policy ront, discussion turned to the need to

be specic about the perormance metrics that will

be used to measure care coordination. There is a

strong need or standardization or reporting across

the community, another role or policymakers in the

coming months. There is also a need to include

small and solo physician practices in development

o care coordination standards and measurement

because o the signicant challenges they ace

in implementation.

Policy Action item(s):

1. Establish a measurement set that will

delineate what outcomes can and should

be measured or care coordination.

2. Create inrastructure that supports all

physicians (including solo/small practition-

ers) to achieve care coordination goals.

There was considerable discussion about the

diculties with implementation o eective care

coordination at the primary care practice level,

which may be addressed through demonstration

projects. Care coordination in most successul

demonstration projects has taken the orm oadditional sta embedded within practices to carry

out the work. For small practices, this increased

capacity is a real-world challenge. Specic prin-

ciples and a ramework or care coordination

operations or the medical home and the primary

care-based ACO should be designed, perhaps in a

learning cooperative environment where ndings

can be collected and disseminated broadly.

There was also signicant discussion around the

role o the patient in care coordination, especially

within the ACO structure. I patients are assigned

providers under an ACO model, we may see

consumer pushback as they perceive their

choices are being made or them, rather than

in collaboration with them. There is a need or

rst principles that reinorce the power o the

primary care/patient relationship, so patients

clearly understand that their health is an asset

worth supporting collaboratively.

26

Reimbrsement polic& aligned incentives

Robst qalitmeasrement

Primar care coordination

teams, health IT, hospitaldischarge planning teams,new pament models

Attention to patient vales

and holistic measres ohealth, accontabilitacross transitions

Policy Levers for Better Care Coordination

Overarching Goals:High qalit, accessible, efcient health care or all

Spported b eective care coordination


29/4827

Demonstration Project Action Item(s):

1. Dvop dsi picips to opatioa-

iz ca coodiatio, at th xt v o

dtai dow om th cossus pap.

2. St xpicit objctivs o ca coodi-

atio aoud th picips o Istitut

o o Hath Ca Impovmts Tip

Aim: Btt ca o idividuas, btt

hath o th commuity ad duc,

o at ast coto, th p capita cost

o ca.

3. Ivov cosums i dsi o w

ca mods to icud cost aoud

ca maamt.

Th was aso discussio about dfi what

costituts succssu ca coodiatio withi th

PCMH ad ACO. Bst pactics i ca coodia-

tio ad cas maamt a sti i ay stas

o dvopmt. Th o o th hospitaist i thca cotiuum has ot b thoouhy xpod,

ad impicatios o coodiatio o d-o-i ca

w ot addssd i th pap. Impovmt i

ths aas os th pottia ot oy o im-

povd quaity, but aso o pottia cost savis.

Research Action Item(s):

1. St up a sach/ai coaboativ

to dissmiat data ad sach om

piots.

David Meyers, MD, Director, Center or Primary Care,

Prevention and Clinical Partnership, Agency or

Healthcare Research and Quality

Debbie Peikes, Senior Researcher,

Mathematica Policy Research

Janice L. Genevro, Ph.D., M.S.W., Lead, Primary Care

Implementation Team; Center or Primary Care,

Prevention and Clinical Partnership; Agency or

Healthcare Research and Quality

Greg Peterson, Researcher,


Tim Lake, Researcher,


Kim Smith, Researcher,Mathematic

Documents

Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations