1. HIV and Primary Care
Transformation: RWCA and the
PCMH
Steve Bromer, MD
Department of Family and Community
Medicine
UCSF

2. Goals
 Why does the US healthcare system need the
PCMH?
 Why should RWCA clinics transform into
PCMHs?
 What is the PCMH model and how close are
RWCA clinics to it?

3. ARS: What role do you play in your clinic?
 Provider (Physician or Mid-level)
 Medical Assistant
 Front Office
 Administrator
 RN
 Social Worker
 Pharmacist
 Other

4. ARS: My practice setting
 Primary Care Practice with HIV Care referred
out
 Primary care practice with integrated HIV
program
 HIV Specialty Practice with integrated primary
care
 HIV Specialty Practice with Primary Care
referred out

5. ARS: Choose the reason
A. To learn more about the Patient Centered Medical
Home (PCMH) as a way to transform our practice
B. To learn more about the details of becoming
accredited/recognized as a PCMH
C. My boss made me come and Baltimore is a cool
city
D. To learn about how concepts from the PCMH apply
to multiply diagnosed populations

6. ARS: Choose the statement you agree with
most:
 HIV patients need excellent HIV specialty care and
primary care is not as important for good outcomes
 HIV patients need excellent primary care and the
HIV specialty care is not as important for good
outcomes
 Both HIV Specialty care and primary care are
important for good outcomes
 With today’s medications, HIV patients will do well
regardless of the quality of their healthcare

10. Mortality Amenable to Health Care
Deaths per 100,000 population*
1997/98
150
2002/03
130
116
109
99
100
76
81
88
84
89
89
97
71
71
74
74
77
80
82
84
93
96
128
115
113
97
88
50
65
90
115
106
134
82
84
101
103
103
104
Fr
an
ce
Ja
p
Au an
st
ra
lia
Sp
ai
n
Ita
Ca ly
na
d
No a
Ne
r
th way
er
la
n
Sw d s
ed
e
Gr n
ee
c
Au e
s
Ge tria
rm
an
y
Fi
Ne
n
w la nd
Ze
al
De and
Un
nm
ite
d
Ki ark
ng
do
m
Ire
la
Po n d
Un
r
ite tug
a
d
St l
at
es
0
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health
Organization mortality files (Nolte and McKee 2008).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.
110

11. Abundant research evidence indicates that
health systems and regions with a strong
foundation of primary care have:





Better population health outcomes
Better quality of care
More preventive care
Lower costs
More equitable care and mitigation of health
disparities

12. Primary Care Strength and Premature Mortality in 18
OECD Countries
10000
PYLL
Low PC Countries*
5000
High PC Countries*
0
1970
1980
Year
1990
2000
*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled
for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R 2(within)=0.77.
Source: Macinko et al, Health Serv Res 2003; 38:831-65.

13. Source: Baicker & Chandra, Health Affairs, April 7, 2004

14. Source: Baicker & Chandra, Health Affairs, April 7, 2004

15. A Functional Definition of
Primary Care:
Barbara Starfield Framework
first Contact
Comprehensive
Continuity
Coordination

16. But the Primary Care Foundation
in the US is Crumbling

Plummeting numbers of
new physicians entering
primary care and
burnout among PCPs

Growing problems of
access to primary care
and “medical
homelessness”

Dysfunctional systems
that are not delivering
the goods in primary care

17. ARS: Approximately what percentage of
adults report difficulty getting a prompt
appointment, phone advice, or
night/weekend care without going to the
ER?
 10%
 25%
 50%
 75%
 90%

18. ARS: What is the average time before
patients are interrupted when making
initial statements to their primary care
physician?





2 seconds
23 seconds
58 seconds
98 seconds
120 seconds

19. ARS: What percentage of patients leave the
office visit without understanding what
their physician said?
 10%
 25%
 50%
 75%
 90%

20. Poor clinician/patient relationships
 73% of adults surveyed reported difficulty getting a
prompt appointment, phone advice, or
night/weekend care without going to the ER.
Public views on of US health system organization, Commonwealth Fund, 2008
 23 seconds: Average time before patients were
interrupted when making initial statement of their
problem to their primary care physician.
Marvel et al. JAMA 1999;281:283
 50% of patients leave the office visit without
understanding what their physician said.
Schillinger et al. Arch Intern Med 2003;163:83
20

21. ARS: What percentage of people in the US
with HTN are poorly controlled?
 10%
 25%
 50%
 75%
 90%

22. Inconsistent Quality
• What percent of people in the US have poorly
controlled
 Hypertension?
 Diabetes?
 Cholesterol?
25%, 50%, 75%??
50% of people with hypertension, 80% of people
with high cholesterol, 43% of people with diabetes
are poorly controlled.
Egan et al. JAMA 2010; 303(20):2043-2050, Ford, Internat’l J Cardiol 2010;140:226, Cheung et
al. Am J Med 2009;122:443

23. The problem: panel sizes too large for
primary care physicians to manage alone
 A primary care physician with an panel of 2500
average patients will spend 7.4 hours per day
doing recommended preventive care.
Yarnall et al. Am J Public Health 2003;93:635
 A primary care physician with an panel of 2500
average patients will spend 10.6 hours per day
doing recommended chronic care.
Ostbye et al. Annals of Fam Med 2005;3:209
Average panel size in the US is 2300 patients
Alexander et al. J Gen Intern Med 2005; 20:1079-83.
23

24. Recognition That Reform and Revitalization of
Primary Care is Essential for ACA and Health Care
Reform to Achieve Its Goals

25. The President
Wants
More and Stronger
Primary Care
“It used to be that most of us had a family doctor; you would
consult with that family doctor; they knew your history, they
knew your family, they knew your children, they helped deliver
babies. How do we get more primary physicians, number one;
and number two, how do we give them more power so that
they are the hub around which a patient-centered medical
system exists, right? ” June 8, 2010, Town Hall with Seniors

26. Senator Orrin Hatch
Senate Finance Committee Roundtable
Reforming America’s Health Care Delivery System
April 21, 2009
“The US is first in providing
rescue care, but this care has
little or no impact on the
general population. We must
put more focus on primary
care and preventive medicine.
How do we transform the
system to do this?”

27. Randy MacDonald, Sr VP
House Ways and Means Hearing April 29, 2009

“I will start with the very last question asked by the
committee--what is the single most important thing to fix in
healthcare? Primary care. Strengthen primary care -transform it and pay differently using a model like the
Patient Centered Medical Home.”

Congressman: “And the second issue?”

“Well, if you don't fix the first issue and do not have a
foundation of powerful primary care then you can do
nothing else. You have to fix primary care before you can
even begin to address a second issue.”

28. A 20 th Primary Care
Model Will Not Meet
the Demands of 21 st
Century!

29. Ryan White: an Unintentional Home Builder
 “An unintended consequence…. of the RW Care
Act has been the establishment of the
comprehensive delivery of multiple services for
patients with a complex disease….medical
homes for the HIV-infected person…..”
 “The act created in his (Ryan White’s) memory,
unintentionally created medical homes that are
the best examples of how all of us should receive
primary care.”
Saag, M. The AIDS Reader, April 24, 2009

30. Quality:
 Cervical Cancer
Screening: 60%
 Oral Health Exam: 36%
 ARV regimens with no
contraindications:
85.6%

31. Workforce The Looming Crisis in HIV Care:
Who Will Provide the Care?
 “In a survey conducted by HIVMA and the
Forum for Collaborative HIV Research, a
majority of Ryan White Part C-funded
programs reported increasing caseloads and
serious challenges recruiting and retaining
HIV clinicians.
 Reimbursement and a lack of qualified
providers were the top two barriers cited.”
HIV Medicine Association, 2010

32. ARS
Workforce: How long have you worked in the
HIV/AIDS field?
1. This is my first year
2. 1-5 years
3. 5-10 years
4. 10-15 years
5. 15-20 years
6. More than 20 years

33. Funding:

34. Engagement in HIV Care
Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December 2,
2011/60(47);1618-1623
HIV Medical Homes Resource Center

35. Will a 20 th Century
Model of HIV Care
Meet the Demands of
the 21 st Century
Epidemic?

36. Joint Principles of the Patient Centered
Medical Home
February 2007
American Academy of Family Physicians
American Academy of Pediatrics
American College of Physicians
American Osteopathic Association

37. Transforming the Delivery of
Primary Care:
The Patient Centered Medical Home
 Ongoing Relationship with
provider for first-contact,
continuous, and comprehensive
care;
 Health Care Team that
collectively cares for the patient;
 Whole-person Orientation,
including acute, chronic,
preventive, and end-of-life care;
 Coordinated Care across all
elements of the health care
system and the patient’s
community;

38. Transforming the Delivery of
Primary Care:
The Patient Centered Medical Home

Quality and Safety through
evidence-based medicine and clinical
decision-support tools, information
technology, registries, and
continuous quality improvement;

Enhanced Access, achieved
through such systems as open
scheduling, expanded hours, and
new options for communication
between patients, their physician,
and practice staff; and

Payment Reform to reflect the
added value that a PCMH provides to
patients.

39. Patient
Centered
Medical
Home
Continuous
First Contact
Comprehensive
Coordinated
HIV Medical Homes Resource Center

40. Evidence on Value of New Primary Care Models:
Case Study of
Group Health Cooperative of Puget Sound
 Patient Centered Medical Home model piloted at
one site in 2007
 Avg PCP panel size reduced from 2327 to 1800
 Longer face-to-face visits and scheduled time for
phone and email encounters
 Increased team staffing and teamwork
 HIT
 Panel management

41. Group Health PCMH Pilot:
Controlled Evaluation 12 Month Outcomes




Improved continuity of care
Better patient experiences (6 of 7 measures)
Better composite quality of care score
Reductions in ED visits and Ambulatory Care
Sensitive Hospitalizations
 No difference in total costs at year 1 (lower total
costs by year 2)
Source: R Reid et al. Am J Managed Care 2009;15:e71

42. Group Health PCMH Pilot:
Effect on Clinic Staff
40%
34.5%
35%
Percent with High
Level Emotional
Exhaustion
33.3%
p=.02
30.0%
30%
25%
Baseline
20%
12 Months
15%
9.7%
10%
5%
0%
Control Sites
PCMH Site

44. Change Concepts for the PCMH
 Engaged Leadership
 Quality Improvement Strategy
 Empanelment
 Continuous and Team-based Healing Relationship
 Organized, Evidence-Based Care
 Patient-Centered Interactions
 Enhanced Access
 Care Coordination
Wagner, EH et al, Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical
Homes; February, 2012

45. The Building Blocks of High-Performing
Primary Care: lessons from the field

23 high-performing practices
 Intensive visits to 7 West Coast practices
 Discussions with and observations of
clinicians, RNs, MAs, front desk, leaders
 High-performing practices look about the
same, with variation in the details
 10 building blocks -- the foundation of these
practices
Willard R, Bodenheimer T: CHCF April 2012

46. Building Blocks of
High-Performing
Primary Care:
Share-the-CareTM Model

47. Change Concepts
Building Blocks
NCQA Recognition
Engaged Leadership
Data for Improvement
Enhance Access/Continuity
Quality Improvement
Strategy
Empanelment, Panel size
management
Identify/Manage Patient
Populations
Empanelment
Team-based Care
Plan/Manage Care
Continuous and Team-based
Healing Relationships
Population Management
Provide Self-Care
Support/Community
Resources
Organized Evidence-based
Care
Continuity of Care
Track/Coordinate Care
Patient-Centered Interaction
Prompt Access to Care
Measure/Improve
Performance
Enhanced Access
Expanded Access Template
Care Coordination
Mission with objectives and
goals
Care coordination with
Medical Neighborhood
Trained Leaders

48. DATA/Quality Improvement Strategy
Formal QI process
Defined metrics
Optimized HIT
Robust data collection
Reporting systems to
share data
Strategic decisions
about metrics
HIV Medical Homes Resource Center
Are we Data Driven
organizations?
Do we use real-time
data on important
clinical/operational
data to guide day-today actions?
Grant requirement to
have CQI, robust
metrics, early adopter
of registry, variable
HIT capacity

49. Empanelment
Assign all patients to
provider panel
Balance supply and
demand
Use panel data to
manage population
Prioritizes patients
seeing own PCP
Clear
denominator at
panel level
HIV Medical Homes Resource Center
Is empanelment a
deliberate process
where we can use
provider panels for
quality data , proactive
care and to actively
manage supply and
demand?
Empanelment not
specific grant
requirement, often
happens because of
structure of practice

50. Team-Based Care
Are our teams organized
around getting the work
done with an explicit
vision and clear
principles? With defined
workflows, skills training
and ground rules?
Patients are connected
to a Care Team
Roles/tasks defined
Culture shift to
share-the-care.
Flexible, functional
teams, with clearly
defined roles
HIV Medical Homes Resource Center
Multi-disciplinary
Teams are central to
RWCA

51. Team-based Care

52. 4. Team-based Care
Why does teambased care matter?
 Align roles to meet
population needs
 Non-clinician teammembers contribute to
continuous healing
relationship
 Build capacity to make
timely access possible
 Foundation for the
Template of the future

53. Traditional Methods of Managing Work Flow
Preventive
Med
Intervention
Chronic
Disease
Monitoring
Medication
Refill
New Acute
Complaint
Test Results
Provider
Healthcare
Support
Team
Case
Manager
Mental Health
Provider
Referral to
Specialist
after
Assessment
Certified
Medical
Assistant

56. Team-based care
• Culture shift: share the care
 Stable teamlets
• Co-location
 Staffing ratios
 Standing orders/protocols
• Defined workflows and roles – workflow mapping
• Training, skills checks, and cross training
• Ground rules
• Communication – healthy huddles, terrific team
meetings and constant conversation

57. Team-based care: stable teamlets
Patient
panel
Clinician/MA
teamlet
Patient
panel
Clinician/MA
teamlet
Patient
panel
Clinician/MA
teamlet
Health coach, behavioral health professional, social
worker, RN, pharmacist, panel manager, complex care
manager
1 team, 3 teamlets

58. Prompt Access to Care
24/7 access to care
team, patient-centered
scheduling
options, address
barriers to access
Balance supply and
demand, open access,
multiple channels of
access
HIV Medical Homes Resource Center
Do we have a patientcentered approach to
access?
After hours
coverage, +/- use of
advanced access tools

59. http://www.careinnovations.org/knowledge-center/knowledge-centerwest-county-healthcenter-video/

60. Population Management/Panel
Management
Plan care according to
need, manage high-risk
patients, point-of-care
reminders
Robust population
management, Selfmanagement,
Complex Case
management, planned
visits
HIV Medical Homes Resource Center
Are we able to focus at
the population level and
proactively assign
resources where
needed? Is data used in
day-to-day care?
Case Management key
feature of RWCA, client
level data, selfmanagement support

61. Care Coordination
Link patient with
community
resources, referral
tracking, coordination of
specialty care
Management of care
transitions, behavioral
health services,
communication of
results
HIV Medical Homes Resource Center
How good are we at
managing the care that
happens outside of our
four walls?
Comprehensive
model of care, often
under one-roof,
expectation that
transitions are
tracked

62. Conscious Trained Leadership/Values and
Mission Statement
HIV Medical Homes Resource Center

63. 100
90
80
70
60
50
40
30
20
10
0
P
C
P
P
C
P
C
C
Series 3
Series 2
Series 1
Engagement in HIV Care
Vital Signs: HIV Prevention Through Care and Treatment -- United States. MMWR December
2, 2011/60(47);1618-1623
=Access
=Care Co-ordination
=Population Management

64. Summary
 Both Primary Care and the RWCA are at a
crossroad
 PCMH is one model of transformation
 RWCA clinics have many components of PCMH
 There is much to learn from PCMH model and
high performing primary care
 Our health care system will have to change to
meet our goal of an AIDS Free Generation
HIV Medical Homes Resource Center

65. Roadmap for Medical Home Resource Center
PCMH concepts in
RWCA Clinics– Action
Planning
Change Management of
Improvement
Opportunities
PCMH Certification
Strategic Planning Workshops
TA and Virtual Learning Community for practice change
TA to support certification
Year 1
Year 2
Year 3