National Healthcare Reform: The Primary Care Imperatives and Strategies for Meeting Them

8/14/2019 National Healthcare Reform: The Primary Care Imperatives and Strategies for Meeting Them

1/29

Excellent Healthcare in Every Neighborhood .

All rights reserved. PCDC 2009

National Health Reform:The Primary Care Imperatives and Strategies

for Meeting Them

Presentation to the American Public Health AssociationMedical Care SectionAvedis Donabedian Award in Quality Improvement Session

Ronda Kotelchuck, Executive Director

Primary Care Development Corporation

Tuesday, November 10, 2009


2/29



A. IntroductionB. Health Care Reform: The Primary Care AgendaC. Primary Care ExpansionD. Primary Care Transformation

1. Practice Redesign2. Health Information Technology

E. Reflections

Overview


3/29


4/29



Primary Care Today:Insufficient and Poorly Organized

Primary care capacity is insufficient: 60 million Americans lack access to primary care

Half of primary care doctors plan to reduce or end their practices Only 20 percent of medical students plan to practice primary care U.S. is expected to need 46,000 primary care doctors by 2025

Most primary care is poorly organized and still practiced in anoutdated mode. It is: Reactive and episodic Subject to long waits and delays Uncoordinated Inefficient


5/29



Study: US Lags Behind other Countriesin Key Primary Care Indicators

11 country Commonwealth Fund study (November 2009) Australia, Canada, France, Germany, Italy, Netherlands,New Zealand, Norway, Sweden, UK, US

US 10 th out of 11 in use of Electronic Medical Records (46%- ahead of Canada)

10 th of 11 in use of care teams (ahead of France) Last in access to after-hours care

Least likely to have financial incentives for clinical outcomes


6/29



B. The Primary Care Agenda: Health Reform WillIncrease Demand for Primary Care

Expanded insurance coverage will put millions of newcustomers in the healthcare market

Physician shortages will increase by 25% and workload by29% over the next 15 years. The Massachusetts experience:

97% coverage 40% of family physicians are not accepting new patients Patients wait months for appointments Record use of ER for non-emergencies


7/29



Rising Costs Will Drive the Need toTransform Primary Care Delivery

Growing evidence shows that primary care is effective inreducing costs, improving health outcomes and eliminatingdisparities

Employers, insurers and policymakers are looking to primarycare as the new paradigm for control costs and increasingimproving outcomes.

A new model of care is necessary, however, to achieve these

objectives. Innovations in practice have been afoot for years (practiceredesign, evidence-based clinical protocols, etc.)

Now these are integrated into the concept of the Patient-Centered Medical Home


8/29



PCDC: Strategies for Primary Care Expansionand Transformation

Non-profit organization founded in 1993 to addressthe lack of good primary care in underservedcommunities

Premier public-private partnership focused onneeds of safety net providers - community healthcenters, hospitals, special needs providers

Three areas of expertise Capital Financing Performance Improvement Policy


9/29



C. PCDC Primary Care Expansion StrategyProblem:

Lack of capital constrains growth of long-standing, dedicatedproviders of care to the underserved; further hampered bythe current credit crisis

Strategy: Use public funds to leverage private investment

Provide favorable-term loans to catalyze construction of new,expanded and renovated sites, modernized facilities Technical assistance to ensure successful project completion

and long-term sustainability


10/29



Results Total investments of $240 million

for 78 capital projects in New YorkState

Created capacity for 550,000 newpatients/1.7M visits annually Leverage more than 1:5

public:private investment Cornerstone of local economic

development: 2,200 permanent jobs created; 4,400 withcommunity multipliers

Facilities operating successfully,no defaults

PCDC CapitalProjects (partial list)


11/29



Joseph P. Addabbo Family Health Center Queens, NY

Before After $9.4 million for new facility

Renovated 22,000 square feetIncreased patient visits by 40%


12/29



Callen-Lorde Community Health Center Chelsea, NY

BeforeAfter

$9.3 million for relocation & expansionIncreased patient visits from 8,000 to

48,000 annually


13/29



Reflections on Capital Strategy for Expansion

Technical assistance is critical for organizations that have littleexperience or internal capacity for undertaking a complex, expensive,risky process

Partnership among stakeholders is key since the respective costs arespread among different parties; all have high stakes in its success

Relative ease of raising capital Creates a permanent community infrastructure

The resulting knowledge and relationships provide a great foundation for other initiatives (e.g., transformation; policy) Offers a replicable model to address the capacity crisis that will follow

national health reform


14/29



D. The Need for Transformation Origin: Initial focus on financial strength of borrowers Discovery of the gap between what is possible and what is.

New realization: Much capacity goes unused because of poor processes. Poor processes themselves become barriers to access

Waits for appointments; lengthy cycle times; high no-shows; staff-focused rather than patient-focusedprocesses; poor customer service The promise of a new primary care model: the medical

home


15/29



A Vision of Transformation:The Patient-Centered Medical Home

The medical home concept: Continuity Well organized (efficient) practice Access: Same day appointment availability, 24/7 telephone access,

alternatives to the 1:1 visit Responsibility for health outcomes

Panel management Decision support Incorporation of evidence based practice (prevention, treatment, management) Care coordination across settings

Patient /family engagement Formalization:

Principles agreed to by major professional associations NCQA standards, measures, system of recognition

Growth of the medical home movement


16/29



PCDC Performance Improvement Programs:Strategies for Transformation

1. Medical Home Assist providers to achieve NCQA recognition andtransformation (also 2 programs below)

2. Practice Redesign Expand access and achieve efficiency byeliminating wait times--both for appointments and during the visitincreasing through-put (productivity), improving patient and staff satisfaction and increasing revenues.

3. HIT Implementation and Meaningful Use Adopt and integratetechnology to improve quality, coordinate and manage care, engagepatients and improve patient-provider communication.

4. Other PCDC Performance Improvement Programs: Attracting and Retaining Patients Increasing Revenue Primary Care Emergency Preparedness


17/29



Performance Improvement PCDC Approach

Focus on: Implementation System Design Measurable Results Staff Organized as Care Teams

Building Client Capability Sustainability

Use of: Change Teams Coaching and Training Collaborative Learning Project Management Frameworks for Improvement

Model for Improvement Chronic Care Model Medical Home Model Change Concepts & Tactics


18/29



1. Medical Home TransformationIssue: Medical home transformation is a difficult, risky, expensive process with many facets and

many entry points.

What We Do Facilitate the NCQA Recognition Process

Tools for Safety Net Providers (Just launched) Consultation and Technical Assistance for Achieving Recognition

Project Management Assessing Status and Setting Goals for Level of Recognition Plan for completing NCQA application; focus on documentation requirements

Assist in Practice Transformation Access and Workflow Redesign Clinical Care Teams Care Model Implementation

Care Coordination and Management Planned Care and Self Management

Meaningful Use of HIT in support of functional transformation to medical home


19/29



2. Practice Redesign:a. Reducing Patient Visit Wait Time

The Issues: Patient visits often average 2 to 3+ hours (for 15 minutes of actual face-time). Long cycle times: signature of poorly organized, inefficient work processes Well-organized, patient-focused work processes: basis for all other improvements.

What We Do:

Work with leaders to establish goals and select a change team. Train and coach team to measure baseline cycle time, track and map current patient visit flow Teach/share change concepts and principles for redesign, including

Bring services to the patient, 2 exam rooms per provider Organize care teams with adequate provider support; leverage provider time Plan and prepare for the day (e.g., huddles, supplies, equipment) On-time performance Real-time communication Do todays work today

Support the Change Team in developing, testing, and refining new patient visit flow over 6-8week period; spreading to full clinic (2 to 4 weeks); anchoring for sustainability (3 months)


20/29



2. Practice Redesign:

b. Accelerating Appointment AvailabilityThe Issues: Patients often wait 3-6 weeks for an appointment; instead go to the ER No shows run as high as 50-60%; providers overbook to make up for no shows Organizations operate well below capacity (25-35%)

What we do: Focus on continuity; establish right-sized patient panels Balance: Optimizing capacity (efficiency processes); moderating demand (care

team & clinical processes) Reduce no-shows; fully utilize reminder calls; eliminate overbooking; see drop-ins

Create permanent capacity for same day appointments; standardize appointmenttypes

Eliminate appointment back-logs; unnecessary visits Efficient flow: Use of care team; on-time performance; planning and preparation;

teamwork; communication Rethink methods of providing services: Telephone, e-mail, group visits


21/29



Practice Redesign Results Trained 219 teams No show rates decrease by nearly 70%

Appointment backlogs drop from an average of 21 daysto 0-5 days Cycle time reduced 50% (to an average of 51 minutes) Provider productivity increase of 33%

Improved patient and staff satisfaction


22/29



3. Implementation and Meaningful Use of HIT

The Issues: Difficult, expensive, risky process Organizations with little experience or internal capacity, few resources Excessive, vendor-generated information; little ability to evaluate Lack of resources (need for sector advocacy, partnership)

What we do: TA for all stages of HIT adoption HIT vendor selection and contracting Planning and readiness

Internal capacity: team building, staff training, project management Design (workflow, decision support) Budgeting

Implementation and go-live Effective use (Assure meaningful use compliance)

Data reporting (Quality, compliance, panel management) Health information exchange


23/29



HIT Results Program

Coached 38 teams through various HIT phases; to date: Selection: 23 Planning and readiness: 11 Go-lives: 6 Health information exchange: 6 Quality use: 2

Remediation: 1 AHRQ research project on use of HIT Clinical Decision Support.

Advocacy Co-founded the Primary Care Health Information Consortium (29 health

centers) State grant program City Council infrastructure support


24/29



E. Reflections: The Nature of Organizational Change The under-appreciation of implementation

People know what needs to be changed. They lack knowledge of how tochange

Transforming the model of primary care requires major, thorough-goingorganizational and cultural change. Myths:

It can been done fast and cheap Its a project. Once done, we can move on to other things.

It can be delegated from the top The importance of technical assistance, willingness to invest in the changeprocess

The under-appreciation of everyday operations Practice redesign, HIT as preconditions for clinical improvements, quality


25/29



Reflections: Keys to Success The importance of leadership

Understanding of the leadership role and the model for change Setting of expectations; demanding results and accountability; establishing

systems of accountability

Building of a leadership coalition Engagement The difference between internal and external leadership skills

Change must be anchored in the everyday business of the organization Policies and procedures; job descriptions, recruiting hiring, training, performance

appraisal. Monitoring, performance reporting

The importance of teams Implications for workforce development, unions, staff roles, organizational culture


26/29



Reflections on Safety Net Settings Private practice

Strong on continuity and access Isolation raises concerns about quality, coordination Setting is simpler, change is easier

Small size, spare resources pose a challenge to acquiring HIT, adding PCMH functions. Community Health Centers

FQHCs offer robust model, many PCMH functions, experience in quality improvement Continuity, access, efficiency not assured

Special Needs Providers Already offer a care home, instinctually understand medical home

Hospital OPDs Broad scope of service available (specialties, ancillaries) Continuity, access, efficiency present challenge in teaching environment Primary care is not the institutional focus or priority


27/29



Reflections: PCDC as a Model for Addressing the Two Challenges:

Expanding and Transforming Primary Care

Generates resources: Total: $315M ($62M public, $253 private) Produces measurable, sustainable outcomes Ability to reach scale

Builds lasting community infrastructure Catalyzes important community economic development Offers excellent platform upon which to build additional programs and

services Works across wide range of provider types (community health centers,

hospitals, private practitioners)

The importance of an organization dedicated solely to primary care Builds a strong community of interest in the success of primary care. Is adaptable to localities, states, foundations


28/29



Contact

Ronda Kotelchuck

Executive Director Primary Care Development Corporation

Phone: (212) 437-3917

E-Mail: [email protected]
mailto:[email protected]:[email protected]


29/29


Excellent Healthcare in Every Neighborhood.

22 Cortlandt Street

12th

FloorNew York, NY 10007

P: (212) 437-3900 l www.pcdcny.org

Documents

National Healthcare Reform: The Primary Care Imperatives and Strategies for Meeting Them