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Redesigning Primary Care:
The Group Health Journey
Robert Reid MD PhD
Senior Investigator
Group Health Research Institute
The Future of Primary Care
The King’s Fund
September 12, 2013
London
Group Health Collaborators
Group Health Research Institute
Paul Fishman PhD
Clarissa Hsu PhD
Eric Johnson MS
Tyler Ross MA
DeAnn Cromp MPH
Katie Coleman MSPH
Eric Larson MD MPH
Ed Wagner MD MPH
Michael Parchman MD MPH
Dave Liss PhD
Onchee Yu MS
Jim Tufano PhD
Kelly Ehrlich MS
Group Health Cooperative / Group Health Physicians
Claire Trescott MD
Michael Erikson MSW
Michael Soman MD MPH
Alicia Eng RN MBA
Barbara Trehearne RN PhD
Gaguik Khatchatorian
Erica Fox
and many, many more….
Funding Support
• Group Health Cooperative
• US Agency for Healthcare Research & Quality (AHRQ)
• Patient-centered Outcomes Research Institute (PCORI)
But, wait just a minute…
• Doesn’t the US outspend all other countries in health care?
• Don’t many US citizens go without healthcare insurance?
• Don’t health outcomes in the US lag the UK?
• Isn’t US primary care in crisis with a dominance of specialist care?
• So, what could we possibly learn?
• Couldn’t the King’s Fund find someone better?
• Was there a last minute cancellation and he’s just a fill in?
.
5
The Importance of Primary Care
(* adjusted for age structure, GDP, mean income, and tobacco/alcohol.)
(Macinko et al, Health Serv Res 2003; 38:831-65.)
High PC Countries
Low PC Countries*
10,000
PYLL*
1970 1980 1990 2000
0
5,000
Ratings of Primary Care Strength and PYLL
(OECD countries)
US Primary Care Challenges
Access to primary care difficult for many, particularly disadvantaged
Quality remains mediocre at best.
Payment systems antiquated. Many valuable functions unrewarded.
Evidence-base for clinicians has become unmanageable.
Primary care unattractive career choice. Burnout common.
The Medical Home: a Concept in Evolution
Joint Principles of Patient-Centered Medical Home 2007
1. Personal physician
2. Physician-directed medical practice
3. “Whole person” orientation
4. Care is integrated & coordinated
5. Assures quality & safety
6. Enhanced access
7. Payment reform
American Academy of Family Physicians. Joint Principles of a Patient-Centered Medical
Home Released by Organizations Representing More than 300,000 Physicians. Position
Paper, 2007
Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System Community
Resources and
Policies
Health Care Organization
Improved Outcomes
The Chronic Care Model
Wagner EH, Austin BT, Von Korff M. Improving outcomes in
chronic illness. Managed care quarterly. 1996;4(2):12-25.
System supports for Chronic Illness Care & Prevention (info systems, practice redesign, self mgmt support, decision support)
Reinvigorating Core Attributes of Primary Care (access, longitudinal relationships, comprehensiveness, coordination)
Supportive physician payment methods (promotes medical home goals, not simply volume)
Advanced information technologies (EMRs, registries, reminders, patient portals)
Medical Home: a Concept in Evolution
Medical Home Growth - 2008-2013
• Rapid growth of demonstrations across the US across in
almost every state
• Many organisations: small and large practices, hospital systems,
large integrated health systems
• Many Different Payers: Commercial plans, state Medicaid
programs, Medicare, multi-payer demonstrations
• Includes Government Systems: Veterans Health Administration,
US Military
• PCMH Recognition Programs: NCQA, URAC, Joint Commission
• Incentives part of national Affordable Care Act
• Base component of Accountable Care Organization (ACO)
www.ncqa.org
NCQA-recognized Medical Homes
Group Health’s Medical Home Journey
(so far)
About Group Health…
• Integrated healthcare insurance
& delivery system started in 1947
•Revenues (2011): $3 billion
•675,000 patients & many payers
•10,000 staff
Multispecialty Group Practice
• ~1,000 MDs (PC & specialists)
• 26 primary care centers
• 6 specialty units, 1 hospital
Contracted network
• >9,000 providers, 39 hospitals
Group Health Research Institute
• $44 million (2010), 60 scientists
• >250 active grants
A little more history….
•Since its origin, Group Health has supported primary care
• In 2000s multiple reforms to improve access, efficiency, productivity
•$40 million invested in electronic clinical information systems
Defined practice populations Multi-disciplinary teams
Specialty care “gatekeeping” Salaried physicians
“Advanced access” with same-day appointing
Leaner teams, shorter visits, more visits
Productivity incentives
System-wide electronic medical record implementation
Features “patient portal” with secure email, results review etc
Decision support tools, reminders & alerts
Ralston JD, Martin DP, Anderson ML, et al. Group Health
Cooperative's Transformation Toward Patient-Centered Access.
Med Care Res Rev. 2009;66(6):703-724
The medical home imperative
Utilization Trends 1997-2005 by Quarter
Inpatient Days
Specialist Visits
Inpatient Admits
Primary Care Visits
ER Visits
Access & Efficiency Reforms
1997 1998 1999 2000 2004 2005 2002 2003 2001
Fre
quency
Inpatient & ER Utilization Trends 1997-2005 by Quarter
Inpatient Days
ER Visits
Inpatient Admits
Access & Efficiency Reforms
1997 1998 1999 2000 2004 2005 2002 2003 2001
The medical home imperative F
requency
Increasing primary care physician burnout
“...the way in which [care] is structured, it has shifted such an increased amount of work onto primary care that it is not sustainable … I’m actually looking to get out of primary care because I can no longer work at this pace.”
“ The burnout rate among my colleagues is huge … those of us that have managed to retain some semblance of balance do it by almost unacceptable levels of compromise, either for ourselves or what we define as good enough care.”
Looming primary care workforce crisis
• Many MD positions remained unfilled
• Shift to part-time practice
• Primary care MDs retiring earlier than specialists
• Most common reason for employment separation: high workload
The medical home imperative
Tufano JT et al. Providers' experience with an organizational redesign initiative to promote
patient-centered access: a qualitative study. J Gen Int Med. 2008;23:1778-83
There has to be a better way!
The medical home imperative
Group Health’s Medical Home
Timeline
2007 2008 2009 2010 2011 2006
Prototype
Design
Prototype
Implementation &
Evaluation
Redevelopment &
Planning for
Spread Staged system-wide
Spread & Evaluation
of Medical Home v1.0
2012 2013
Redevelopment
Medical Home v2.0
Medical Home Design Principles (2006)
The relationship between the primary care clinician &
patient is at our core; the entire delivery system will
orient to promote & sustain.
The primary care clinician will be a leader of the clinical
team, responsible for coordination of services, and
together with patients will create collaborative care plans.
Care will be proactive and comprehensive. Patients
will be actively informed and encouraged to participate.
Access will be centered on patients needs, be available by
various modes, and maximize the use of technology.
Our clinical and business systems are aligned to achieve
the most efficient, satisfying and effective experiences.
Group Health’s Medical Home Prototype
MD Panel size
1,800 2,300 PCMH
model:
Enhanced &
co-located
Teams
“Desktop”
medicine time
Appointments
20 min.
30 min.
Value-based
payment
incentives
Medical Home Staffing Changes
37
Medical Home Staff Roles
•All outreach by any member of the team is comprehensive. For example: pharmacist call
regarding medications address prevention care gaps (cancer screening).
• Team huddles
• Visual display systems
• PDCA improvement cycles
• Removal of RVU incentives
• Calls redirected to care teams
• Secure e-mail
• Phone encounters
• Pre-visit chart review
• Collaborative care plans
• EHR best practice alerts
• EHR prevention reminders
• Defined team roles
Point-of-care changes
• ED & urgent care visits
• Hospital discharges
• Quality deficiency reports
• e-health risk assessment
• Birthday reminder letters
• Medication management
• New patients
Patient-centered outreach
Management & payment
PCMH Model
Group Health’s PCMH Prototype
PCMH Prototype Evaluation
Patient
experience
Staff
burnout
Evaluation
measures:
Quality Utilization Cost
• Quasiexperimental, non-randomized intervention & matched control
study design with baseline and follow-up data collection at 1 & 2 years
• 2 control clinics for patient & staff surveys; 19 control clinics for
administrative data analyses
Reid RJ et al, Health Affairs 2010;29(5):835-43
Reid RJ et al, Am J Manag Care 2009;15(9):e71-87
Medical Home Components Year 1: 94% more emails, 12% more phone consultations,
10% fewer calls to consulting nurse, & other changes
Year 2: Changes persisted
Patient Experience Year 1: small, statistically significant changes in 6/7 scales
including access, quality of MD interactions, care planning
Year 2:Changes persisted in 5/7 scales
MD & Staff Burnout Year 1: Emotional exhaustion dropped by half at medical
home with no change in controls.
Year 2: Changes lessened but remained significant
Utilization Year 1: 29% fewer ER visits, 11% fewer preventable
hospitalizations, 6% fewer but longer in-person visits
Year 2: Significant changes persisted
Costs Year 1: No significant difference in total costs between
Medical Home and control patients
Year 2: Lower patient care costs approached stat
significance (~$10 PMPM; p=0.08)
PCMH Prototype Evaluation
New questions emerge…
Are the results generalisable to Group Health’s other clinics?
What will happen when practices don’t “invent” it?
What spread methods to use & how to stage?
Are the leaders & managers up to the task?
STAGED SPREAD OF PRACTICE CHANGE MODULES
Call Management Team Huddles Standard Mgmt Practices
Enhanced Staffing Model Value-based MD Payment Model
SUPPORTED BY CHANGES TO MANAGEMENT, STAFFING AND MD PAYMENT
Standardization & Spread using LEAN Techniques & Tools
Group Health’s PCMH Spread
Virtual Medicine
Care Management
Visit Preparation
Patient Outreach
PCMH Spread Evaluation
Question Method Challenges
Changes to
Efficiency &
Quality?
• Interrupted time series
(60 mos)
• Non-equivalent control group
of network patients
• No true control group
• Secular trends
• Co-interventions
• Evolving re-design
Changes to Patient
Experience?
• Patient focus groups (low and
high complexity)
• Patient experience survey
• No true control group
Changes in Staff
Experience?
• Semi-structured interviews
with clinical staff
• Staff survey (burnout, team fn)
• Representativeness
• No control group
How were Practices
Transformed? What
Factors Influenced
Success?
• Direct observation of
leadership meetings
• Leadership interviews
• Clinic site visits and interviews
with front line staff
• Leadership & staffing
changes
Evaluating the Medical Home Spread
• Process Evaluation - implementation change targets met for
most of the PCMH modules across all clinics
Hsu C, Coleman K, Ross TR, et al. J Amb Care Manage. 2012;35(2):99-108
Evaluating the Medical Home Spread
Reid RJ, Johnson EA, Hsu C, et al. Ann Fam Med 2013;11:S19-S26
Phone
Face-to-face
Evaluating the Medical Home Spread
Reid RJ, Johnson EA, Hsu C, et al. Ann Fam Med 2013;11:S19-S26
✗
✔
✔
Learning Healthcare System
Green SM, Reid RJ, Larson EB. Implementing the learning health system: from
concept to action. Ann Intern Med 2012;157:207-210
Next Steps: Medical Home version 2.0
Key Changes to Group Health’s Medical Home :
Patient-risk Stratification to better target human resources
Move team members to practice at “top of licensure”
Strengthening the primary care teams: “relational coordination theory”
Integrating with the Medical Neighborhood: integrating mental health,
chemical dependency, and specialty care into in the primary care teams
Developing a patient-centered community liaison role
Medical Home Transformation in
Community Practices
Eight “Change Concepts” Required for Practice Transformation
1. Engaged Leadership
2. Quality Improvement Strategy
3. Empanelment
4. Patient-centered Interactions
5. Organized Evidence Based Care
6. Continuous Team-based Healing Relationships
7. Enhanced Access
8. Care Coordination
Wagner EH, Coleman K, Reid RJ et al. Defining a patient-centered medical
home. Primary Care: Clinics in Office Practice. 2012;39(2):241-259
Some final thoughts….
• Redesign represents significant change in how doctors, nurses
& care team members think about their job
• Patient needs, desires, and perspectives should be primary
• Primary care physicians & team members need to “own” the
changes and it must “work” for them
• Strong leadership and management is key
• Invest in a long term journey with many improvement cycles
