The Patient Centered Medical Home at AltaMed Health ServicesEsiquio Casillas, MD, MPH

Michael Hochman, MD, MPHOctober 13, 2015

AGENDA• Background about AltaMed• The PCMH Model• AltaMed PCMH Model• Senior Buena Care (Program for All

Inclusive Care for the Elderly)

PCMH

Founded as the East Los Angeles Barrio Free Clinic in 1969, a volunteer-staffed storefront operation

Now the largest independent FQHC in U.S., serving over 170,000 patients annually

Serve safety net population 28 sites in LA and Orange Counties (including

Primary Care Clinics, HIV, PACE and Mobile Service Sites)

Programs & services include: general medicine, dental services, senior services, women’s health, pediatrics, youth services, HIV services, health education, obesity prevention

About AltaMed

AltaMed- Patient Demographic

Patients by Hispanic or Latino Ethnicity

Hispanic/Latino Non Hispanic/ Latino

Unreported/ Refused to Report Total

139,381 (81%) 30,323 (18%) 1,428 (1%) 171,132

Insurance: None/uninsured: 31,993 (19%)Medicaid: 109,247 (64%)Medicare: 6,685 (4%)Other public insurance, non-CHIP: 1,267 (1%)Private insurance: 21,940 (13%)

BIRTH OF THE PCMH MOVEMENT• Concerns about sustainability of

primary care in the U.S.• Desire to increase primary care

revenue

PCMH

THE PCMH MOVEMENT• Primary care organizations lay out

principles of primary care (2007): “The Patient-Centered Medical Home (PCMH)”

PCMH

PCMH PRINCIPLES• Personal primary care provider• Whole person orientation• Coordinated care• Enhanced access to care• Emphasis on quality and safety• Team-based care• New payment models

PCMH

TEAM BASED CARE• It’s not all about super-human primary care

doctors!

PCMH

What Does the Evidence Show?

Group Health: 2002

• Online patient interaction with clinic:- emails with PCP- med refills

• Advanced access scheduling• Direct access to specialists• Incentives for PMC productivity and patient

satisfaction (40% of salary)

Results

• Impact on patient satisfaction:Positive

• Impact on staff satisfaction:Negative:

- bigger panel sizes, emails, productivity pressures

Results

• Impact on ER/hospital visits and specialty visits:

increased

Group Health: Take 2 (2006)

• Decreased PCP panel sizes from 2300 to 1800• Visit time increased from 20 to 30 minutes• Daily ‘desktop time’ for care coordination• Team-based care!!! (RNs, MAs, PAs, NPs, and

pharmacists)

Group Health: Take 2

• Daily team huddles• ED/hospital follow-up outreach• Continued emphasis on email and phone

communication with patients• Eliminated productivity incentives• $16 per-patient per-year investment

Results

• Impact on patient satisfaction:positive

• Impact on staff satisfaction:positive

• Impact on quality of care:positive

Results

• Impact on ER/hospital visits:Positive:

- 29% fewer ED visits- 6% fewer hospitalizations

Results

• Impact on cost:Positive:

- $16 per-patient per-year up-font investment- $10.30 SAVINGS per member per month

(P=0.08)

Lessons

• PCMH-guided reform has the potential to improve primary care

• Requires investment• Team approach very important• New payment models will be critical to enable

sustainability

ALTAMED PCMH MODELPCMH

Physician andMedical

Assistants

Nurse Practitioner and

Medical Assistants

Physician Assistant and

Medical Assistants

Physician andMedical

Assistants

Care Coordination

Team

Care Coordination

Team

Care Coordination

Team

Care Coordination

Team

CARE COORDINATION TEAM• Clinical Care Coordinator = RN Case Manager• Health Promoter (Health Coach)• Behavioral health (LCSW/psychologist)• Clinical Pharmacist• Mid-level chronic disease manager

PCMH

RN CASE MANAGER• Target the most complex patients

(‘hotspotters’)• Caseloads of 200-33 patients• Also sporadic assistance

PCMH

HEALTH PROMOTERS/HEALTH COACHES• Target patients with stable chronic

illnesses• Lifestyle teaching, education, action

plans• Goal: 5 visits per day

PCMH

CHRONIC DISEASE MANAGEMENT• Pharmacists as population health managers• Mid-level chronic disease managers

PCMH

BEHAVIORAL HEALTH• 7 LCSWs/clinical psychologists• Depression/anxiety counseling

PCMH

TEAM-BASED CARE• Daily huddles• IDT/ICT

Case Management

COMMUNITY APPROACH: OBESITY• CDC REACH Grant• County Health Department, YMCA, local

grocery stores, restaurants• Parks and Rec• Food trucks

Innovation

CHALLENGES• Team based care• Fee for service• Standardization throughout the system• Partnerships with hospitals• Patient engagement

PCMH

28

AltaMed Health Services(PACE)

Program of All-Inclusive Care for the Elderly

An integrated Health Plan/Medical Group designed to provide complete access to

Medical, Social, Psychological, Transportation, Homecare, Nutritional,

Rehabilitative services, End of life through one comprehensive program.

VERTICAL INTEGRATION AT PROVIDER LEVELPACE Basics

PACE REGULATORY FRAMEWORKPACE Basics

County/State Regulation

ADHC

Transportation

CDHCS Regulation for Licensure or Waiver

Dietary Health Dept Regulation

Clinic CDHCS Regulation

PACE

CMS PACE Regulation Medi-Cal RegulationCDHCS Contract

• 108 PACE programs nationally-32 states• 30,000 enrollees nationally• PACE programs in California

• On Lok in SF and Fremont• CEI in East Bay• AltaMed Senior BuenaCare• Sutter Senior Care in Sacramento• St. Paul’s in San Diego• Fresno-PACE• Jewish Home of Aging• Cal-Optima-Orange County• InnovAge-Riverside/SB County• Redwood Coast/Eureka

PACE PROGRAMSPACE Basics

HEALTH AND WELL BEING

• Health care accounts for 10% of contributing factors in life expectancy

• Social determinants of health account for 60% of risk of premature death

Adapted from McGinnis, Russo and Knickman. “The case for more active policy attention to health promotion.”Health Affairs, 2002.

SOCIAL DETERMINANTS OF HEALTH

85% of physicians believe unmet social needs are directly leading to worse health

80% of physicians state they are not confident in their capacity to address their patients’ social needs

Health care’s Blind side: the overlooked connection between patients social needs and good health, RWJF, 2011.

SOCIAL DETERMINANTS OF HEALTHPhysicians wish they could write prescriptions to help patients with social needs

1 out of 7 prescriptions physicians write would be to address patients’ social needs• Fitness program 75%• Nutritional food 64%• Transportation assistance 47%

SOCIAL DETERMINANTS OF HEALTH

PACE Basics

IDT- COMPREHENSIVE APPROACH

NursingSpecialists

Primary Care

PT/OT

Adult Day Health Care/Activities

Social WorkPharmacy Home Care Coordinator

Transportation Personal Care

Dietary/RD

PACE Basic

PACE OUTCOMESImproved health status

Higher patient satisfaction

Improved physical functioning

Increased days living independently in communityImproved quality of lifeLower mortalityLower hospitalization ratesHigher utilization of primary care services

PACE Basic

PACE OUTCOMES

PACE Basic

PACE OUTCOMES

ALTAMED-PACE PROGRAMAltaMed

• ~1900 patients• 25 Providers (110 Patients/Provider panel)• 8 Sites• Patients at PACE Center ~9 days/month• ~80% patients receive maintenance PT-OT• 14 Transportation round trips/month/pt• ~20 Meals/month/pt• ~70 Caregiver support service hrs/month/pt• Required Biannual IDT Assessments• Minimum Q-6 week clinic visits

RISK ADJUSTED SCORINGAltaMed

UTILIZATION

0200400600800

10001200

Admits/1000

Admits/1000

AltaMed

Milliman ACN Report, AltaMed UM 2012 ytd,C-SNP-XL Health

UTILIZATIONAltaMed

SNF Beddays/1000

Duals-Custodial 29,634

Duals-Community 2,506

C-SNP 1,887

AltaMed PACE 1,460

UTILIZATION-SNF BED-DAYSAltaMed

AltaMed

ALTAMED PACE FALL RATE PER 100 MM/QUARTER

52

PACE-HIGH RISK MEDICATION %AltaMed

0

5

10

15

20

25

2010 2012 2013 2014

QUALITY MEASURES

• Pneumococcal vaccine rate = 95% • Nephropathy screening in Diabetes = 96%• Hospital Discharge f/u visit within 72hrs ~ 90%• Readmit rate ~ 14%• Patient Satisfaction-Would refer friend/family =

96%

AltaMed

AltaMed PACE

LOCATION OF DEATH

AltaMed PACE

POLST ANALYSIS

PERMANENT NURSING HOME PLACEMENTAltaMed

COMPLEX HEALTH CAREPACE Basics