Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Â
Session 7 - Patient Centered Care
1. Patient-Centered Medical Home
Ambulatory Care for the 21st Century
Kevin A. Dorrance, MD, FACP
Chief, General Internal Medicine Service
Walter Reed Bethesda
September 2011 7-1
5. Outcome Measures
Continuous Enrollment Impact (quarterly utilization and cost)
Total Chronic Non-chronic
Cont Cont
Average Cont enr Average Average
Change enr Change enr Change
use impact use use
impact impact
IP adms 0.0351 -0.0176 -50.0% 0.0780 -0.0421 -53.9% 0.0097 -0.0032 -33.4%
IP days 0.2455 -0.1472 -59.9% 0.5440 -0.3399 -62.5% 0.0636 -0.0351 -55.1%
ER visits 0.1775 -0.0388 -21.9% 0.2828 -0.0953 -33.7% 0.0821 -0.0037 -4.5%
Specialty
2.4688 -0.2319 -9.4% 3.4033 -0.4031 -11.8% 1.1993 -0.0519 -4.3%
care
Primary
1.8293 -0.0190 -1.0% 2.4037 -0.0868 -3.6% 1.0023 -0.0015 -0.2%
care
Pharm. $91.10 $4.83 5.3% 156.31 -$2.13 -1.4% 22.40 $3.43 15.3%
Ancillary $83.42 $3.52 4.2% 118.01 -$0.43 -0.4% 43.82 $4.61 10.5%
PMPQ $481.51 -$38.09 -7.9% 791.67 -$123.3 -15.6% 174.94 $2.46 1.4%
7-5
6. Outcome Measures
WRB Medical Home Impact(quarterly utilization and cost)
Total Chronic Non-chronic
Average PCMH Average PCMH Average PCMH
Change Change Change
use impact use impact use impact
IP adms 0.0215 -0.0009 -4.4% 0.0439 0.0074
IP days 0.1016 0.0193 19.0% 0.2098 0.0393 18.7% 0.0331
ER visits 0.1574 -0.0107 -6.8% 0.2204 -0.0161 -7.3% 0.0891
Specialty
2.2454 0.0535 2.4% 3.1946 -0.0989 -3.1% 1.0203 0.1480 14.5%
care
Primary
1.5037 0.3199 21.3% 1.8500 0.5002 27.0% 0.9396 0.0011 0.1%
care
Pharm. $112.16 -$14.45 -12.9% $182.90 -$25.41 -13.4% $27.49 -$2.35 -8.5%
Ancillary $104.23 -$16.57 -15.9% $144.80 -$25.06 -17.3% $53.95 -$6.76 -12.5%
PMPQ $507.49 -$46.67 -9.2% $784.00 $-83.16 -10.6% $187.44 -$13.29 -7.1%
7-6
7. Outcome Measures
WRB Medical Home Impact by Condition
Hyper- Hyper- Mental
Diabetes tension lipidemia COPD CAD health
IP adms -10.8%
IP days 20.2% 19.0% 36.0%
ER visits -13.5%
Specialty care -3.6% -0.5% 3.4%
Primary care 40.3% 32.0% 32.1% 46.3% 49.3% 24.8%
Pharmacy -17.0% -16.1% -17.0% -10.3% NA* -1.4%
Ancillary -16.2% -19.1% -15.2% -24.0% -24.1% -14.1%
PMPQ -10.5% -11.1% -10.0% -10.1% -8.2%
NNMC enrollees 1,595 7,098 7,207 960 659 2.426
7-7
8. Outcome Measures
Cost Impacts Associated with Chronic Enrollees
Change
Non- attributable
Chronic chronic Total to chronic
Estimated costs per enrollee
PMPY without PCMH $3,136 $750
PMPY with PCMH $2,803 $697
Change -$333 -$53
Change -10.6% -7.1%
Average PMPY change by percent chronic
40% -$165 80.7%
50% -$193 86.2%
60% -$221 90.4%
7-8
9. Outcome Measures
The Bottom Line
 Care delivered by primary care physicians in a
patient-centered medical home is consistently
associated with:
 Better outcomes
 Reduced mortality
 Fewer hospital admissions
 Lower utilization
 Improved patient satisfaction
 Lower Cost
7-9
11. Here We Are
So Young and So Many Pills
Prescriptions for anti-hypertensives in people
age 19 and younger could hit 5.5 million this
year if the trend through September
continues, according to IMS. That would be
up 17% from 2007, the earliest year
available. Still, a growing number of studies
have been done under a Food and Drug
Administration program that rewards drug
companies for testing medications in
children.
Wall Street Journal, 28 Dec 2010
7-11
12. Here We Are
So Young and So Many Strokes
 Researchers at the CDC analyzed hospital
data on up to 8 million patients a year from
1995-2008; in Annals of Neurology, they say
stroke rates in five to 44-year-olds rose by
about a third in under 10 years
 The rate of ischemic stroke increased by
31% in five to 14-year-olds, from 3.2 strokes
per 10,000 hospital cases to 4.2 per 10,000
 There were increases of 30% for people
aged 15 to 34 and 37% in patients between
the ages of 35 and 44
BBC News, 2 Sep 2011
7-12
13. Here We Are
US Life Expectancy at Birth, by Sex, 1900-2003
7-13
14. Here We Are
US Life Expectancy at Birth, by Sex, 1900-2008
If trends in
chronic disease
continue, we may
live longer—but
sicker—lives.
7-14
15. Here We Are
Top 10 US Public Health Achievements
 Vaccination
 Motor vehicle safety
 Safer workplaces
 Control of infectious diseases
 Decline in deaths from coronary Health care has had little
heart disease and strokes to do with increased life
 Safer and healthier foods expectancy over time.
 Healthier mothers and babies
 Family planning
 Fluoridated drinking water
 Recognition of tobacco
as a health hazard
7-15
16. Here We Are
Leading Causes of Death in the US
1900 1997
Pneumonia 11.8% Heart Disease 31.4%
Tuberculosis 11.3% Cancer 23.3%
Diarrhea/Enteritis 8.3% Stroke 6.9%
Heart Disease 6.2% COPD 4.7%
Liver Disease 5.2% Injuries 4.1%
Injuries 4.2% Pneumonia/Flu 3.7%
Cancer 3.7% Diabetes 2.7%
7-16
17. Here We Are
Comparing Leading and Actual Causes of Death
7-17
18. Here We Are
Current Healthcare Model
Primary
Care Primary
Care Is
Episodic Devalued
Hospital Emergency
Room
Disease
Uncoordinated Model
Network Specialists Ancillary
Care Support
Community Nursing Assisted
Homes Living
7-18
19. Here We Are
The Consequences
 Episodic model of disease care
 A growing prevalence of preventable chronic
diseases—75% of direct health care costs
Our continuing failure to proactively monitor and improve
the overall health of our population has facilitated the
growth of our current disease model of care.
7-19
21. Here We Are
Tuning the Yugo
 Disease management
 Pay for performance
 Performance-based budgeting
 Balance score cards
 Lean six sigma
 Clinical microsystems
7-21
24. Our Story
 HA PCMH implementation
Team-Based
policy memo signed 9/1/09 Healthcare Delivery
Access
 Linking PCMH model to Care
Population
Health
with Quadruple Aim of
“Accountable Care” Patient the
Advanced Center of Patient-
 PCMH Resource IT Systems Med Home Centered
Guidebook for MTFs Care
completed
Decision Refocused
 BUMED Primary Care Support Medical
Tools Training
Patient &
Instruction – “Medical Home Physician
Feedback
Port” 5/26/10
 Second Annual Tri-Service
Medical Home Summit 2010
7-24
25. Our Story
Traditional Workflow Design
Chronic
Preventive Disease Medication
Medicine Monitoring Refills Acute Care Test Results
PROVIDER
Healthcare
Support Case Behavioral Medical
Team Nursing
Manager Health Assistants
7-25
26. Our Story
Parallel Workflow Design
Behavior
Point of Modification Chronic
Care Testing Disease
Chronic Acute
Disease Acute Compliance
Medication Test Care Preventive Mental
Monitoring Barriers
Refills Results Medicine Health
Complaint
Healthcare
Support Behavioral
Team Health
Case Medical
Manager Assistants
Provider
PROVIDER
7-26
27. Our Story
Health Care Delivery Team
 Team concept (clinical micropractice): IM, FM, PA/NP, RN, LPN
and clerical support
 Collaborative: all members engaged in preventive and
chronic care
 Team members work up to level of training
 Integrated care model
 Behavioral health into the delivery system
 Self-management support
 Proactive preventive and chronic care
 Appointing: data-driven and patient-centered
 Coordination
7-27
28. Defining Access
• What is access?
• Does it = Supply – Demand?
• Is this a simple linear relationship?
7-28
29. Our Story
Improved Access to Care
 In-person encounters
 Telephone
 Automated medication refills
 Secure messaging
 Telemedicine
 Open access to preventive care
7-29
30. Our Story
Improved Access to Care
 Reducing artificial demand
 Chronic/preventive care
 Proactive appointing and asynchronous visits
 Open access
 Patients are seen when they need to be
and when they want to be
7-30
31. Our Story
Population Health Management
An integrated set of health delivery
programs that proactively monitors and
improves the fundamental health of a
given population
We have more personal control over what
we are dying from than ever before.
7-31
32. Our Story
The Population Health Management Model
Preventive
Care
Acute Care
At Risk
Chronic
Care
The Population
7-32
33. Our Story
The Integrative PCMH
 Medical home team ownership of all aspects of the
population
 Provides patients with tools and support to improve
their health and keep them healthy
 Includes integrated health services: psychologists,
nutritionists, mind-body therapists and other
professionals at the point of care
 Includes a set of IT tools and preventive measures to
monitor outcomes and help patients take
ownership for their own health
7-33
34. Our Story
Integrated Health Services
 Programs
 Behavioral health
 Dietician
 Health education
 Mind-body medicine
 Pharmacy
 Benefits
Provides assistance to patients when habits, behaviors,
stress, worry or emotional concerns about physical or
other life problems are interfering
with their daily lives
7-34
35. Our Story
Lessons Learned
 Culture change: don’t underestimate
 Training, team building
 Productivity: does it matter?
 How do we measure non-traditional care?
 Staffing model: what is optimal?
 Transformation: where to start
 Based on patient demographics
 Wellness focus: population health has to be at the
center of all elements of care
7-35
36. Our Story
Deployment Timeline
NNMC Sept 2008
~ 2009
Pediatric
Team 2 Rollout
Department
Jan 2009 Sep 2009 Implementation
June 2008
Teams 3, 4 Medical Home
Team 1 Rollout
Rollouts Summit
2008
2009 2010
Sep 2009 ~ 2010
NMC SD Enhanced
Team NMC SD MH
Navy
Creation
Medicine Complete
7-36