Narrator: Elsevier Gold Standard is pleased to sponsor “Building a Better Medical Home” and to support all initiatives that improve medication safety and patient outcomes. For more information about Elsevier's drug decision support and medication therapy management solutions, please visit goldstandard.com.
David May: Thank you. Now we have a few housekeeping items to address before we proceed: Your phones will stay in listen-only mode during the entire webcast. However, listeners can send questions throughout this event. Our moderator will try to ask as many as possible before. You can find the questions window on the right-hand side of your screen connected to the webcast dashboard that appeared when you first joined the call. A recording of today's discussion will be available on our website, ModernHealthcare.com/webinars. Within a few days, all attendees will receive a follow-up email, including a link to that recording. Slides used during today's presentation will also be available online. And now, I'd like to turn the webcast over to Andis Robeznieks, Modern Healthcare reporter and the moderator for today's webcast. He will introduce our panelists. Andis.
Andis Robeznieks: Hello. Thank you. I'm reporter Andis Robeznieks, and I cover physician affairs for Modern Healthcare and Modern Physician. Today, our panelists are Dr. Somava Stout. She is the vice president of patient-centered medical home for the Cambridge Health Alliance, which is a Harvard University-affiliated public healthcare system. We have Dr. Jim King, who is the medical director of the Prime Care Medical Center in Selmer, Tenn. Dr. King is also the former president and board chair for the American Academy of Family Physicians. And we also have Dr. Karen DeSalvo, the commissioner of health for the city of New Orleans, currently on leave from her position as vice dean of community affairs and health policy for the Tulane University School of Medicine. We'll begin with you Dr. Stout.
Somava Stout: Thank you very much. I'd like to begin by saying that all of us have our sense of what it takes to become a patient-centered medical home. But I'd like to share that all of our journeys are somewhat different. The idea of what a patient-centered medical home is really if you think about building a home that you make, you meet with an architect, there are some foundational elements that have to be in place for everybody—foundation, walls or roofs—but what you put inside the home, what's on your walls, how you paint those walls, how you flow from one room to another, these things are different. So, what I'll share with you is as we've begun the process of transitioning all of our ambulatory sites to patient-centered medical homes caring for and beginning to think about how we provide outstanding care to a community of 100,000 patients, what we've learned along the way over the last several years of our journey. And so the first and foremost element that we've found that we need to become a patient-centered medical home is an unrelenting focus on meeting the needs of patients. That means understanding what those needs are, finding different ways to not only measure patient experience but patient outcomes that help us to get to beyond the first layer of what patients might be able to return to us in a survey. We've found that the development of infrastructure in primary care in the form of care teams that are organized and empowered to reliably meet the needs of patients and population have been absolutely foundational and critical. The development of systems that support teams to be successful and gives the information they need to do their job easily. And I include here information technology systems. While certainly to meet NCQA [National Committee for Quality Assurance] criteria to be a medical home, [you] don't have to have an EMR, it's actually incredibly valuable to be able to exchange information electronically to have all of the appropriate information accessible at the fingertips of every person who is interfacing in a patient's care and to be able to use an electronic medical record to be able to harvest information that helps teams know whether they're being successful in providing excellent care. You need a road map for the journey, and I think the NCQA process offers up some of that road map, but it's important to make that road map yours along the way. And you need to be able to share learning with people across one's own institution and ideally to be part of a national conversation that's going on today about how we improve primary care to become more patient-centered, coordinated and [unclear: 5:37]. It is incredibly important to align incentives so that people aren't trying to change to create better care with a payment system that supports them just to see a volume of patients rather than to provide quality care to patients. And fundamentally what we've discovered in our journey is that this is a process of cultural transformation. Actually at the Health Alliance, we've become incredibly committed to this process. In the next several slides we'll describe sort of some of the core elements of our journey and some of the core lessons learned along the way. Next slide, please.
I wanted to just say a word about the role of NCQA recognition because this always comes up, and the role that that's played in our journey. We developed our vision to become a patient-centered medical home not based on a call for a proposal or based on the NCQA standards. We decided to do it because when we had a process of re-envisioning what we wanted our healthcare system and our model of care to look like, we realized that we wanted to create a healthcare system that for a safety net population that would reliably meet patients needs, provide outstanding team-based care and provide a sustainable care system for the workforce. So that a sustainable workforce transformation [unclear: 7:08] speaking of primary-care providers and really everybody who takes care of patients. The NCQA recognition provided a really helpful road map of what some of the foundational elements of our medical home journey needed to be. So it helped to create common standards that were the national standard around access, care management, patient tracking, and what some core elements needed to be in place. But we used it as a launching pad to think and envision about what we really wanted our care to be. At this point, two of our sites have become Level III NCQA-recognized sites, and that was out of a total possible of 100 points. By the time they applied, they were scoring in the 95 and 96 range out of the total of 100 points. You need 75 points to get the NCQA Level III, so what was fascinating about that journey is that as we did this, our most advanced sites realized that their vision of what they wanted to do to provide outstanding patient-centered care went far beyond the NCQA screening mark, and I think it's important to consider the NCQA process as a road map—perhaps as a milestone on the journey, but not the destination in and of itself. There are new standards for the NCQA process, and doing this process has been incredibly helpful for us. Our plan is for all of our sites to become NCQA-recognized within the next two years. But I think that understanding that fundamentally medical home transformation isn't about meeting a recognition criteria, but rather about creating deep cultural transformation and creating systems about how you realize we provide patient-centered, team-based, coordinated care has been important. Next slide, please.
I wanted to say a word about how we've gone about creating cultural transformations. One of the things we've found critical to do is to make sure that the decision about the what that we'll become a patient-centered medical home might be something that a group of leaders perhaps but decide, but fundamentally it needs to be something that everybody on the staff not only understands but buys into and becomes part of creating because fundamentally this is about how we see ourselves as accountable for patients at a whole different level than we might be used to. Before, we would just think that we needed to provide excellent care of the individual in front of us. As you become a patient-centered medical home, you recognize that you are responsible for a population of patients whether they're there in front of you or not and that it is our responsibility and privilege to be able to serve patients in a much more comprehensive way as a whole person to help bridge their mental, physical, social health in a whole different way. This really requires the entire staff to become engaged in creating the vision so every step of rollout of medical home, long after it entered vision documents, every time we roll out to a site or to a new group of people, we do something that we actually ask people in small groups of six to take on the role of a particular patient—a 22-year-old single mom with a 2-week-old or an 67-year-old Spanish-speaking gentleman with an amputee patient and say ‘If you were this patient, what would you want your healthcare system to look like?' Interestingly, every time we've done this exercise—we've probably done this a few hundred times by now, you always have covered that some of the most core principles of a patient-centered medical home and it helps us to make that vision of what we want to become as a healthcare system and what medical home is something that's personal and aligned with what staff want inherently to do when they go into healthcare, which is to provide excellent care for patients. But you need to back up this cultural transformation with concrete things like leadership development—and we've really done this not just at primary care but across primary-care specialties in patient units to say that these principles of providing accessible, highly coordinated, highly satisfying seamless care are principles that should govern how we provide care across the system. And that leaders and managers need to understand how to mediate those kinds of transformation in their units. Having teams engage in designing the implementation at their sites have been crucial, so at our lead sites we have work flow teams, which include people like medical assistants, front-desk people, nurses, providers all working together to say, ‘How should we achieve population management for diabetes?' or ‘How should we take care of the people who need flu vaccinations' or ‘How should we improve the flow so that patients aren't waiting a long time to be seen?' and ‘How do we improved access?' These are decisions that have been—the standards have been created at a more system level but the how has often been created and modified at the local level and then supported, again, at the system level through some level of standardization. And this process of making this one's own has been fundamental to creating sustainability. Empowering teams to own the outcomes is really about empowering every member of the team to be responsible for a particular outcome. So we have front-desk people who see themselves as champions of getting patients signed up for patient portals and to educating them about their [unclear: 13:02 ?views?], and medical assistants to see themselves as quality leaders for achieving reductions in achieving improvements in Pap smear screening ratios or colorectal screening rates. And have access to all the reports that are needed, but really see themselves as owning this report. When the care of primary care is owned in its this kind of way it creates—it makes it possible for us to take what is otherwise an incredible amount of work and to distribute it. And it actually empowers people to create and give them joy and meaning in their work—whether they're a provider or a member of the staff. And that's, fundamentally, what we found is necessary to create sustainable transformation. Next slide, please.
This idea of team-based care is probably the most foundational element of our transformation besides EMR implementation, and it would take a whole 'nother time to talk about that. But in talking about team-based care empowering the entire team to become sort of caregivers, we've really done this very systematically. We've scheduled a team to be working together during the usual care of patients, during visits, to be meeting as a team to think about population management on a weekly basis. What this has done is it's allowed us to take the 22.6 hours of work a day that is estimated it would take to take care of an average panel of 2,500 patients and divide it up among more people so it's possible to achieve the outcomes we want to achieve. What we found was that by doing this, we've give the patient not just one person that can support them in their health but a whole set of people who they know and feel incredibly connected with. This is a patient who's actually given me permission to share their picture along with Ada who is her medical assistant. This relationship and continuity of relationship between the provider but also the rest of the care team, including the medical assistants and the patients, has proven to be incredibly important in improving everything from access to population management. In the next few slides, we'll quickly go over some of these. Next slide, please.
This is an example of some of our outcomes we've been able to see. This is a community which had a waitlist for primary care that was nine months long when this model was created, and this health center was started using a patient-centered medical home model of care that now has reduced its waitlist for new patient appointments to reliably one to two weeks. Next slide, please.
In the same community, for instance, we've seen Pap smear screening rates go from 40% to over 90%, and I could show you the same slide for colorectal screening, diabetes screening, etc. It's really about substantially improving health by catching illness early and being able to treat it early. Next slide, please.
Doing medical home transformation is—I don't want to in anyway sugarcoat it. This is hard work. It's about changing how we do our work, and it's about fundamentally taking on actually a whole additional amount of work that we didn't take on before when we were just thinking about the patient in front of us, which is the [unclear: 16:3 ?keystone?] in population health. It's also about taking accountability for things like access in a whole different way where we have to understand what is our demand for services and how do we meet that demand in a reliable way? What's been crucial for us is to try to structure this in a way where people go from feeling like they have an unsustainable job to thinking about how can we do this in a way that creates sustainability for everyone? But also what Ed Wagner has proposed should be the fourth aim. There's a triple aim, which is improve patient experience, improve population health, reduce cost of care, but the quadruple aim that Ed Wagner, the founder of the chronic care model has proposed, is joy and meaning of work, and this has been something that has been very important for us in our thinking of how to create medical homes in a sustainable way. This is applied after participating in a work group to improve patient experience across the health center where the majority of people who were able to participate in the process which is actually all but four people felt like they could say now that they were satisfied with their current job and had reduced burnout in their current job. Next slide, please.
This again sort of shows people feeling like they have—over 90% of people saying, ‘I have no symptoms of burnout or only occasionally feel stress at work.' This ability to not only create systems but just creates a human system that support medical home transformation in a sustainable way has been crucial for our journey. Next slide, please.
I wanted to end with what I would call a medical home fable. We've collected a number of these over the years. We actually began to use the process of improving outcomes for childhood asthma at Cambridge Health Alliance with pursuing perfection several years ago. This was actually one of our foundations for our medical home. We created teams that had access to put asthma on the problem list. Putting asthma on the problem list triggered a set of activities and reminders. Proactive outreach was done to patients by planned care team members. Patients became controlled in asthma medications by 99%. We partnered with public health to do home visits for people with poorly controlled asthma. To help families identify issues, we formed partnerships with school nurses to have access to the full continuum of a patient's medical record and care plan. And what we saw was actually really dramatic. Next slide, please.
Inpatient admissions for—next slide, please. Inpatient admissions for asthma actually completely disappeared after this initiative. I could show you the exact thing for emergency room visits, and this is just dramatic. There were an incredible amount of cost savings as a result of this initiative. So when people wonder, ‘Do medical homes save costs?' I think we've seen plenty of evidence that it does. What it meant for us as a system though was that we actually has to close the pediatric inpatient unit, and that was for the population exactly the right thing to do. But when you're a health system that's trying to make healthcare better, if the incentives aren't aligned so that the health system can accrue some of the savings that are generated by improved care, the system quickly loses—it can quickly lose its incentive to keep trying to improve healthcare to work more effectively and in a more coordinated way for patients. We at Cambridge Health Alliance are deeply committed to improving the health of our communities. We're a public health system. We feel strongly that it's our mission to reduce costs, improve patient care and to have a stewardship over the cost of that care. But, for us, discovering that aligning incentives is crucial has been a fundamental and important part of our recognition moving forward. And so we're on our journey to become an accountable care organization if we can and to really transform the entire health system along these principles to become a patient-centered medical neighborhood. Thank you very much.
Andis Robeznieks: Thank you very much, Dr. Stout. And one question for you. I had heard some criticism that the patient-centered medical home is really in fact a physician-centered medical home. Can you describe how perhaps some practices go astray in this manner, and can others avoid this pitfall?
Somava Stout: I think that the idea of a patient-centered medical home initially throughout a pediatrics which actually the model is about how you improve care for pediatric patients with chronic pediatric diseases. And then it became a primary-care workforce issue, as we saw providers weren't—since primary-care providers weren't sustainable in their practice. And I think the conversation sort of became reframed about how to help primary-care providers stay in practice. What we found is it needs to be about both, and fundamentally having the focus be about patients and about creating—thinking about it as creating sort of sustainable human infrastructure, sustainable teams that are sharing the care of those patients, and empowering the entire team to not just see themselves as being assistants to the physicians but as being empowered to provide care in a meaningful way to patients has, I think, it's been a huge—it's a very different message when you say it that way. But we found that we have to lift that way, too. So that means the information and medical knowledge that medical assistants or front-desk members bring, which we eventually found to be priceless. And their leadership in helping to figure out how to say to everybody, ‘Here's what we need to do to provide—here's the path to providing excellent care.' How can we as a whole team work together to make this work—understanding the constraints on the provider and what they're able to do, but really helping everyone to sort of work at the top of their roles and their license to be able and to have that be accompanied by a sense of joy and meaning and contribution to the patient's health I think has been really important in framing this for us.
Andis Robeznieks: OK. Well, thank you very much. And just in case anyone in our listening audience isn't familiar with the organization, the NCQA is the National Committee for Quality Assurance. And there are different organizations offering medical homes certification and accreditation and recognition programs, but the NCQA's recognition program is the most widely used. And, Dr. King, if you're ready, we'll begin with your presentation now.
Jim King: Thank you, Andis. As Andis introduced me, a few years back I was the president of the American Academy of Family Physicians, and during that time, we worked on forming what's called the ‘Joint Principles of the Patient-Centered Medical Home' along with the general internists, pediatricians osteopathic physicians and came up with some policies. And then my job as president was to go around the country and try to talk our 93,000 members who are all family physicians naturally into becoming one. And I've done that over the last two years, but now that I've rotated off of our board, I'm back in my small practice.
Now I have to convince six doctors, because we have seven physicians in our group and three nurse practitioners, that we need to make some change, and one of the things I found back in practice is it's significant change in our practice. This requires a lot of work, energy, money and commitment for us to do these things because there are a few concepts that have to truly do a 180 to make things happen in our practice that were mentioned a little earlier. And one is that team concept. Jim King can never be a patient-centered medical home, and no other physician can be. It is a team or your practice that becomes that patient-centered medical home. That team does consist of the nurse that works with you, your receptionist that answers the phones, your other office staff, the subspecialist that I refer to and that send my patients back to me.
Other healthcare professionals like physical therapists, dieticians, the pharmacist down the street, all of those people are working with me to help my practice make my patients healthier. Now they've introduced the hospitalist concept. There's so many primary-care physicians who are not going to the hospital that you have another handoff where your patient goes under someone else's care for a time before they come back to you. And it's very vital that team is communicating with each other in how to take care of our patients. Most of our practices are in silos. You're managed in the hospital, and you're managed in the office and you're managed in another place. And those places need to be able to communicate, and that's part of what's going on with our patient-centered medical home. Even a small rural practice like we have. Like I said, we're a practice of seven physicians, three nurse practitioners with three practice sites. We've been on electronic health records now since 2004, and it's just amazing how much just communication from our three sites is important of us getting that information.
So the team concept is very vital to make this work. The next thing is the patient-centered part. Now the healthcare system in my office was not patient-centered; it was doctor-centered. We started seeing patients when I wanted to see patients, I spent as much time I wanted to see with my patients at that time, I ordered what I wanted to do for my patients and I thought would help them, but it was physician-centered. It's moved to the point that it's insurance company-centered. They tell us what we can do, what we can't do. We're having to jump through hoops for insurance companies; the employers may be centered around the healthcare system or the hospital or the government, but it just wasn't patient-centered. So in way of changing back to becoming patient-centered, one of the things that our practice had to do was simply do what was mentioned earlier. I asked my staff, I asked other physicians: ‘Put your staff on the end of that table or the other side of that counter, and what would you like to have done for you and then do it.' And that's one of the major changes that we feel like needs to happen in our offices.
One of the things with access that we're doing in our practice that has helped that is simply that you talked about appointments two days, three days, two weeks, three months before you can in to see someone. We have same-day appointments in our office. Now to do that, what we had to do was to only schedule about half of them in advance so that when people called in that day, they could be seen that day. Physicians get a little antsy when they're standing around and not seeing patients because they're not coming in quick enough. They're worried about that. Remember we were physician-centered, so we wanted the doctors to stay busy all the time. And what happened was that patients had to wait in the waiting room longer. Sometimes they weren't seen for a day or two, but now with same-day appointments we're seeing everyone within 24 hours of the day they make the call. Another problem that we had was we had patients that had minor problems that needed to be seen quickly and get in and out and back to work. We have what we call our ‘fast-track' program access. And that simply means that the patient can call in and if they have a minor problem then we guarantee that we will see them within inside of 30 minutes and get them home or back to the office wherever they needed to be.
Now our patients had to give up a couple of things in that particular process: One of them they have to give up is knowing exactly who they see because all of our guys and gals want to see these patients. So what we do is we make a special room, and in that room when a doctor or provider walks out, and they see that room is open and has someone in it, they'll go in it immediately and see the patient so we can get them in and out. They don't get to choose exactly which provider they see. The other thing the patient has to give up is the by-the-ways.
They can't come in for a sore throat and say, ‘By the way, I want all my blood work done or I need an EKG or [unclear: 29:19] done, because we're trying to work people in and out quicker. But it's not fair for me to tell a 26-year-old lady with two kids and one kept them up all night with what she knows is an ear infection that we're going to work them in and they need to come in about 2 this afternoon and they know they're not going to be seen until 5. So it's working a lot better but it's adding access. We're thinking about what the patient's needs are to improve that. And that's one of the changes that we made in our practice. Another major change in concepts and the way we deal with patients is moving from the individual patient to the community of patients. A family doctor is good at taking care of a patient when it's time that they're sitting at the end of that table, but the ones that don't get into the office are the ones we need to start becoming concerned about and try to take care of.
And as you start to think about your community of patients that have diabetes, that need their cancer screening, that has hypertension, then you're all of the sudden, you're trying to work to get patients in that aren't getting the care they need. And we start measuring how well we're accomplishing that. So with the change from taking care of one patient at a time to taking care of a community of patients, there's another change we need to do. The other thing is I'm a firm believer—of course I should be—that family doctors do a great job of taking care of their patients. But we haven't really measured that in the past. We've not been able to prove it. Now with pay-for-performance and quality measures, we're being able to start to determine those numbers so we have a better idea. I know in my practice that I have 167 diabetics in my practice. Of those, I know 90% of them have had a hemoglobin A1c done this year. And just over 10% have one that's higher than nine that I need to continue to work on. In years past I didn't have that data. I didn't know. Now, that we're gathering that data, we're starting to work on those patients that need the added care, and the ones that aren't in as good control, the ones that and not coming in for their screenings that they need. We're trying to get those patients in so with good doctor-patient and quality information, that we're getting out of our electronic health records, we are now able to provide higher quality of care and managing those chronic conditions that we have to manage in our practices.
So, for the family doctor, you got to realize that we take care of it all. I mean, my patients have osteoarthritis, diabetes, hypertension, heart disease, depression. They don't like their mother-in-law, and their dog got run over a couple of days ago. We have to deal with all of that. So it becomes very important for us to have that kind of data so we can work on what the main problem is the patient has maybe that day or the ones that need the most care dealt with, because we can't give all of our time, but with the help of delegating and working with some members of the team we can take care of all of those type of things. You know, if you try to get into a physician's head, a lot of people don't try to get into our heads, but if you think about it you're asking us to do something different. And that's what we're doing with the patient-centered medical home concept. We're asking the doctors to do something different. And in doing that, the first thing that we do think about: Does this improve the quality of care for our patients? The second question we ask is: Is it going to make my life easier? Is it going to make it easier for me to take care of my patients? And lastly, naturally, is what does it do to my bottom line financially? Can I afford to do this?
Well the quality data's now starting to come out. It's been shown, in fact, previously that with a patient-centered medical home, you can improve the quality. Now we're finding that the lifestyle change is tough. Any change is tough. So as we begin to make the changes, we're starting to see some of these things as we delegate, as we do other things, that maybe we're adding more quality. The satisfaction is improving. One of the examples in our own practice was a couple of years ago, in giving the pneumonia vaccine, we made a change in what we do. And, for example, everybody over age 65, everybody that should get a pneumonia vaccine we told the nurses, ‘Ask if they've got it, and if they haven't, give it to them.' We ran out of the pneumo vac in two days. Because what we had always done in the past is simply wait till flu season, and when we gave them their flu shot, we would say, ‘Have you had your pneumonia shot?' But we were losing a lot of our patients to their flu vaccine because they were going to the health department, a health fair, a hospital. They were going to Bed, Bath & Beyond to get their flu vaccine. So we weren't taking those opportunities to find out if they were getting all of their vaccines or not. But with that change in our policy, now a higher percentage of our patients are getting the appropriate vaccines they need.
So it's trying to make a change and be able to delegate and get the team working together. Now on costs, one of the major problems as I went around the country was this cost-prohibitive—the cost of putting in electronic health records. The cost of making those changes most practices saw the value, but they started saying, ‘I can't afford to do this.' And it's similar to the example that a lot of people have given, the time of trying to work on your car while it's moving down the road. As we're working we're seeing patients and doing as much as we can, and you're asking me to change everything I'm doing while I'm doing that. It was hard to do. Plus it was costly in buying the electronic health records, and the other thing. So some of the money that's starting to come forward is helping practices make that change. The PQRI [Physician Quality Reporting Initiative] payments that we're getting, e-prescribing payment and, of course now, the stimulus money with EHR adoption that you can get money from making changes. But we're being taught new words and new things that we have to do, such as, mentioned earlier, the NCQA designation, being able to come there, the meaningful-use with your electronic health record. Our own practice has found that to do that we're going to have to upgrade to the next version of our computers because the version we're in now doesn't do that. And then we do have to make several changes in some of the processes, and it gets kind of difficult and hard for us to do. But insurance companies and others are coming forward now with added payment for pay-for-performance, for disease management, and these incentives on the front-end to help make the changes as we see practices begin to move in this direction. I guess what I'd like to leave this group is a couple things. No. 1 this is not easy for a practice to do, and the easiest thing to do is just keep doing the same thing even though everybody's starting to realize that the changes will improve the care they we provide and in the long run will probably save money and make the system more efficient. And with that, I'll be glad to close and answer any questions you might have.
Andis Robeznieks: Yes, Dr. King, I have heard stories too that the increased access that you talk about and the fast-tracking of patients, some patients misinterpret that as, you know, they're used to the long waits, and then when they can see a doctor right away they think, ‘Well maybe the practice is in trouble and that's why they can get in so quickly.' And I was just wondering if there were any other aspects of the medical home that perhaps patients misinterpret or don't feel comfortable with right away?
Jim King: I think, well, there's a couple of things. A lot of practices and the changes that we do the patients may not notice at all. I mean with the quality measures and doing some of the things and bringing up [36:54 unclear], other problems they may not notice those changes. But I've really not heard anything negative in any of the changes that we've had in our own practice. Of course, I'm in a rural town, so everyone knows me and knows my partners as well, so they know that we're trying to make this change to add more services to them. And it is amazing. You know, I gave the story of our fast-track program. I've honestly had patient's mothers who've come in and almost were in tears thanking us because, you know, they have two other kids to take care of, and just knowing that we saw them at their time—we have tried to show that we care about their time is just as important as our time is a very important aspect that the patients appreciates. They appreciate us worrying about their health instead of just trying to solve a problem every once in awhile. Family medicine is one of the greatest things in the world. We're one of the few groups that get to meet with our friends all day and maybe, just maybe, have a positive impact on them. So I've really not experienced any negative things at all in our practice in the move as it relates to our patients. My pushback is usually from my partners and my staff, which was mentioned, who just really are resistant to change.
Andis Robeznieks: OK, well thank you very much, and Dr. DeSalvo please begin your presentation.
Karen DeSalvo: Hello everybody. Thank you for the chance to share our story in New Orleans and in Louisiana of how we have been implementing the patient-centered medical home. And I'm going to tell the perspective first from that of New Orleans where I'm the commissioner of health in the city, but part of that was part of developing a medical home in the community and also as the president of Louisiana Health Care Quality Forum, which has a statewide focus of implementing and facilitating this development statewide. Next slide.
So, for those who are not familiar with our state, I think it's important just to put some context that six years ago almost we took opportunity from this tragedy of Hurricane Katrina and saw soon after that the Aug. 29 devastation and flooding that we actually had an opportunity from that clean slate to rebuild a health system to replace one that had been really poorly performing. We had some of the highest costs but worst quality and very limited access to primary care in our communities statewide but also in New Orleans, and in addition had not just poor quality of care and high costs but poor health outcomes for the population-at-large, ranking 49th or 50th in the united healthcare rankings on an annual basis for the 15 years running into the storm. And the population that was needing to be served is very high risk, high percentage of uninsured individuals, very strict eligibility from Medicaid, leaving us really dependent on institutions like public hospital systems that weren't able to really meet the needs of primary care, and we certainly did not have a distributed network of primary care at the time to rely upon and thought that this was our chance to develop a new blueprint and a new future. Next slide.
And so beginning in early October of 2005, a few weeks after that sad storm, the community across the state came together bringing stakeholders from business and providers and payers, consumer representatives and physicians, nursing groups, etc., to lay out a blueprint for Louisiana for healthcare reform with an eye on New Orleans being the testing bed for the ideas that we wanted to see carried forward. And we really broke it down into four major areas: one is to redesign delivery to focus more on primary care and less on hospital-based care. We had ranked fourth in the nation for emergency room visits for ambulatory-care-sensitive diagnoses like asthma and heart failure, hypertension, diabetes, and so we really knew we needed to change the right door or put the right door out there for people to enter so they had options in their neighborhoods. And of course this was 2005, and the notion of the patient-centered medical home was well-embedded in pediatrics and family medicine worlds. It was just coming into the consciousness strongly of internists, which is what I am. And we were right around the time as was previously described, the joint principles were being developed. And so we were following that locally, and realizing that our neighborhood-based care needed to not just be primary care of an ordinary variety—no offense to anyone—but good, good primary care that had those tenets of those joint principles of the patient-centered medical home that were emerging. We wanted to make sure that we were availing ourselves of everything that we would need to do to support the community with good access to really strong primary care. Well, that was one. No. 2 was to improve the quality of care, develop a shared-quality agenda and an effort around that. That is actually with the quality form merged from that stream of work as well as some other efforts that are now under way to focus on diabetes and cardiovascular disease to improve the quality of care that those high-risk populations receive. And the third area was to get better tools to support providers, which meant implementing health information technology. We had lost our legacy systems, including our paper records. And so this was a chance to test out in New Orleans the rapid implementation of electronic medical records and health information exchange, which we have been hard at work doing even across the states. And the fourth area was to change the way we pay for care and give more people coverage. We certainly in that bucket of work definitely experimented with payment reforms, the kind of coverage that actually didn't come about but is now moving forward in the state, but in all of these areas we've made some progress in our test-bed in New Orleans and now across the state. Next slide.
That policy framework was very purposeful and planned, and took us about a year to come to terms with but we were simultaneously working on building prototypes of all the things in the community, and that happened somewhat accidentally because we planted the seeds of community-based care and the notion of electronic medical records and improved quality, etc. really from the first-aid stations that were set up around town. Again, we had not had much primary care in the community but most of the services were hospital-based with some exceptions. But what sprang up through volunteerism by and large was this neighborhood-based sites sometimes in a grocery, sometimes in a dormitory, sometimes in a church, wherever there was a dry place with a roof that we thought might get electricity. And we learned some things working in that environment that helped to shape our notion of a patient-centered medical home, and now moving forward into the bigger idea of a neighborhood—a patient-centered neighborhood. So the kinds of things that we learned, for example, were that team-based care and a team approach where everyone gets to work at the top of their license is more effective, and frankly enjoyable for the providers working in that environment. That mental health needed to be integrated into our primary-care work as well as services that addressed social determinates of health. It's partially because population in our cities, a historical high risk of poverty and low literacy and economic challenges, but also because, of course, the disaster and the impact that had on people's livelihood and housing and mental health situation. We also had the luxury of working first under emergency rule and then through global budgets. And physicians and providers in the group and especially in primary care will understand that very often the way we are paid in primary care is to just keep doing more as opposed to doing better, and this was a chance for us as providers to really create teams to focus on populations of people we were dealing with and think about how to proactively reach out to them, how to be responsible for the quality of their care in aggregate, and to have to plan because we had very limited resources, and we needed to know as soon as we could from the data that we had collected how many diabetics, how many asthmatics, how are we going to order supplies, and how are we going to begin to stand up the patient-centered medical home? What is the [unclear: 45:37?social service?] that we would need? Next slide.
And so over time that policy framework merged in with our prototypes that we built on the ground in the efforts of numerous organizations and individuals and with input from patients and policymakers about what this network would come to look like as our prototype, and, indeed, where we are today is that we successfully created a loosely affiliated network of patient-centered medical homes. We have, I believe still, the distinction of having the highest density of patient-centered medical homes in urban area. We have about 42 recognized sites. They're mostly all primary care. Interestingly, some are actually mobile units and mental health providers. This was sort of surprising for some of us, but I think what it taught us is that the tenants of the patient-centered medical home were that if you're doing the right thing by team-based care, quality, accessibility, that you can meet those criteria without what we might traditionally think is the trappings of a big box of primary care. It's really much more about the focused service and what you're doing every day. In all there are 25 different organizations who stepped up and agreed to share in a pool of grant money that we received as part of our recovery dollars of $100 million to take care of the population and the four parish area in the greater New Orleans area, and over time we implemented as many as 90 access points of care, again, including mobile units and pool-based health centers, mental health and the bulk of it being primary care also offering mental health that serves in a given year 20% of the greater New Orleans population. That's about 200,000 people a year providing quality primary care. About 75% of those community health sites are using electronic medical records, and we are a Beacon Community through the National Office of the Coordinator for Health Information Technology, which means that we are developing health information exchange that will allow us to share data as long as patients agree horizontally between these providers and then vertically with the hospital system and specialists who are also at the table for that project. We have learned some lessons about quality. Initially we let each of the organizations decide what they would use as their goals based on population needs, i.e., ‘I have a lot of kids with asthma, I'm going to focus on that' vs. someone else who might have more need for cardiovascular disease. In this next round of quality work, as part of our waiver in the Crescent City Beacon Community project, we're actually focusing on diabetes and cardiovascular disease so that we can say at the end of three years we made a difference in those two major important winnable battles and we know that we've improved the quality of care for those high-cost and high-risk conditions. And then finally, the payment piece is we were and are still working on this waiver payment that essentially pay on what we call a ‘population capitation.' So, each provider would provide a list of the blinded patients that we didn't know the names but uniqueness of individuals who were part of that practice, and were paid on a six-month basis to take care of those individuals but it was all rolled up into a big global numbers. So it wasn't a certain amount of money per individual; it really was for that whole population. We had to have auditing to make sure that the practices were submitting a correct list that was part of the expectations of the grant. And then were paid that respectively going forward based on a look-back of data. And then that same cycle would happen again. There was evaluation for access and service through mystery shopping, through quality reporting, and then of course a pretty intense financial oversight as long as the practices stayed within budget for allowable expenses, patients had access and quality care was achieved, and if patients had reported a good experience, then the payments continued.
We're now in a waiver, which is a different form of payment, using something called ‘disproportionate share,' which typically goes for hospitals. And we're still working on that payment scheme. It may look more like what the professional societies have recommended for global payment and a fee-for-service on top with some quality bonus. But what we're still sorting out the exact nuances of it. I'll just say that the goal is to have a coordination of care core payment, because that makes a difference in the kind of team you can build. What we built there in addition to primary care in our medical home is by and large there is embedded mental health service at every site. So there's a warm handoff. If I, the primary-care doc, see somebody who I know needs mental health services, I have someone there that day, that time, that can walk in the room and address that patient's needs. Even going beyond that, many of the clinics universally screen for mental health issues like depression so that there's not a doctor having to make the decision or a nurse. It's automated in a standardized two-item survey first and then a more detailed assessment. Many of the communities have wrapped around legal aid, community health workers, social work into these clinics so that there is a [unclear: 51:02?panacea?] of services to address the social needs of these patients so that they can then be more empowered to address their chronic disease care management. We know from work that the Commonwealth Fund has done, Kaiser Family Foundation and there's some ongoing assessment by UCSF. We know some things now; we'll no more in the future about our cost effectiveness. But what we do know is that the patients receiving care in this network clinic, about 43% are uninsured. They're sicker than the average American. They're more likely to be a minority. They're poorer than the average American. But they report less indebtedness from healthcare costs. They report significantly higher satisfaction with their care. And we have been able to retain physicians through deliberate policy action, not just in the payment scheme but through some loan-repayment programs, and we've gone from having one of the worst [51:50 unclear] for primary-care providers in the country to being in the top 10% nationally. And I'll tell you as a primary-care physician having worked in a variety of systems, this is such a pleasant way, the medical home, to practice medicine because you actually have a team that can wrap around that patient and that population. And you can work top of your license with everyone else doing the same. Next slide.
Next I just want to share with you that what we're learning as our test-bed in New Orleans as part of that Blues front has been exploited across the state. The notion of a patient-centered medical home has been implemented through NCQA recognition across the rural environment, other cities in Louisiana. We have a pilot going on in Alexandria, La., with a private insurer who's working with a couple of private businesses to experiment on a slightly different model targeting a different population. Their success has been good so far. Maybe they can talk on the next call. Just in January, Medicaid is going to be re-launching patient-centered medical home certification expectation and payment methodology, somewhat predicated on what we've done in New Orleans to expand that to patients statewide. This is no small number of folks, about a million people across the state who are in the Medicaid program. Eight-hundred thousand will be eligible to be in that patient-centered medical home framework, and Blue Cross Blue Shield is using that as a model for their Bridges to Excellence program, and will be continuing to march forward on expectations about supporting and paying for primary care differently so that it's not just an experiment in idea, but, indeed, everybody has access to this kind of good quality care. Next slide.
My last two comments have to do with, for us the patient-centered medical home is in the context of a bigger idea about health and healthcare. Clearly the primary care is the door of choice, and we want to make sure that everyone has access to that, and that it's sustainable. But we also know that patients need other services in the continuum, be that specialty, diagnostic, hospital-based, and so working with the rest of the healthcare system through linking HIT to thinking about payment reform and shared-quality agendas is a way that we're bringing everyone to the table so the neighborhood is focused. Louisiana—we don't have very much managed care, and so it's not the kind of payment environment that some other states have where payers really drive as many of the decisions about the development of ACOs. And so we are really doing this on a very grassroots level with providers working cooperatively to see it happen. And then, of course, the patient within the community spends much more time there that they do with us. So working very tightly with social service agencies and neighborhood associations and other institutions that will have an impact on the health of communities, whether it's better access to fresh foods, whether that's strong social networks that people need, places to exercise. Those are all things that matter just as much to these patient-centered medical home, particularly in New Orleans, and will make a difference, we think, in the long term in people's health and not just their healthcare. Thank you.
Andis Robeznieks: Thank you, Dr. DeSalvo, and I had some follow-up questions ready for you that the audience had sent in, and you kind of addressed some there at the end, but specifically people were wanting to know about whether the medical home has to be primary-care centered or if a specialist has a role. And also about the role of mental health, which is something you did talk about.
Karen DeSalvo: The specialists have a role in patient-centered medical home and particularly, as we've learned from the pediatrics world, that they've been successful in using that framework to develop specialty-focused medical homes for kids with major chronic issues. I think in adult populations, if you think about individuals on dialysis, cancer patients, heart-failure patients, it's clear actually that some of those specialties have already created team-based care in that kind of approach. So, there are already models that exist in the wild I'll call it, and so absolutely this—what this gets down to for us in Louisiana is that it is a structure for good patient-centered care that's using evidence-based protocols, that's using evidence-based thinking, population-based approach, high accessibility and a team to wrap around patients and populations so that it's not just episodic [unclear: 56:48 ?office or one-off?] visits with doctors. The mental-health component is one of the most important things we have to deal with as a country. We have too long marginalized that as a part of overall health. It makes it clunky to build and pay for in primary care, but there are some models—not only in Louisiana but in other big institutions like Kaiser and the VA—that are trying to bridge those two worlds financially and structurally so that patients don't have to have a gap in those services, that those handoffs are warm handoffs that happen in a more invisible way and in a more patient-centered way than they have historically.
Andis Robeznieks: OK, well thank you very much. And for Dr. Stout, we got a couple of questions from the audience asking for elaboration on the figure you used 22.6 hours for 2,500 patients. If you could speak to that and just kind of elaborate a little bit more on how that was factored?
Somava Stout: Actually this is published in a 1993 New England Journal of Medicine article, which looked at for a panel of 2,500 patients, how much time it would take to meet the needs for patients' acute care, preventive care, and then chronic care. And it turns out that just for preventive and acute care, I believe it's 17 hours, and if you add acute care it's 22.6 hours of a day. Those aren't my figures. Those are published figures. Unfortunately, since 1993 there have actually been many more recommendations added, so we might be well over 24 hours for the day. I think it's in that same article, it was noted that right now in primary care we only meet 55% of recommendations in each of these measures. I suspect it might be because the average primary-care doc working alone sort of drops after about 11 hours working straight. So the system actually achieves exactly what you think it would achieve.
Andis Robeznieks: Well thank you very much. And we do have a lot of questions, so we're planning on going about 10 minutes longer if that's OK. And next question is for Dr. King. People were wondering about the coordination of care between your practice and hospitalists, and what is the role of the electronic medical records and the health information exchange?
Jim King: In our small town, to let you know what we got, the larger hospital where we send to the subspecialists—is about 45 miles from our community. So we're not on the medical staff there. So if any of our patients go or need to see a cardiologist or gastroenterologist or have a surgical procedure, that's where they go. Some of the things that have happened—well, for the hospitalist when they first started, I guess the major problem that we always had was we would get the history and physical back within about three to four weeks after the patient was discharged. And that was the only document we saw. We never saw the discharge [unclear: 59:40]. And a lot of times we didn't know our patient was even in the hospital, and they would come back and say, ‘Well, they've sent us back'—they sent you back to me, but you don't know. Now we've done a few things with electronic health records. We can go online now and look at the day-to-day on what the history, the labwork, the tests that are done at that particular facility.
We have sign in that we can get that information if a patient comes in and tells us that. Also, we're starting to develop better communication between the hospitalists and ourselves. It's a two-way thing. They need to know what I know about my patient when they're admitted, and I need to know what they did while they had my patient in the hospital. And we're starting to share that information better. There's an understanding now that I need to have that information when the patient comes back on what medicines they changed, what new medicines they're on, what things they found. And it's been done now on the Internet. There is a difference. Like I said, I can go online and see everything that happened in the hospital. We're developing with the subspecialty groups ability that they can online and go into our system and look at and get that past medical history. So as we break down those silos, the care's got to improve—and also utilization will improve and efficiency will.
Somava Stout: Can I add something about that?
Andis Robeznieks: Sure, go ahead.
Somava Stout: So Boston is a little bit of a bigger town [laughs]. And as you know, there are many different health systems, so we have patients admitted to many places. One of the things that we've been able to do is to really use, again, the electronic medical record to tie in not only to all of the hospitals that are within our system but to help us connect with other hospital systems. And so the thing that we've done underneath that is just sort of build the idea that we are all part of the same team across whether it's hospitalists, emergency rooms, care providers taking care of a group of patients. So as we've built that culture of communication, and across specialties as well, one of the things that's wonderful now is that specialty notes, emergency room notes, inpatient notes, those all come automatically to my electronic in basket as a primary-care provider, even without me having to do anything, which is really helpful as I go about my busy day. But the other part is that the care team has been leveraged so that not only do I receive a communication when a patient is admitted by a hospitalist, because we talk with each other because we see ourselves as part of the same team. And I get the discharge summary, but the discharge instructions, which are done in a way that's very easy for patients and family members to understand, also is sent to the electronic medical record to our nurses. And our nurses automatically outreach to the patient within a day or so to make sure that the patient is doing well at home, has their follow-up appointment, has the appropriate medication. And this ability to sort of see ourselves—we talked about what it means to be a patient-centered medical neighborhood. For us, it's meant, that partly, specialty practices also develop accessible patient-centered, coordinated care. But it's really meant about connecting the different parts of the healthcare system so that we together are providing coordinated care and are supported by systems to help provide coordinated care seemlessly.
Andis Robeznieks: OK, thank you. Dr. DeSalvo, can you speak to the role of IT in your network and also what it took to get the physicians to use it?
Karen DeSalvo: Be happy to. Louisiana is one of two states that actually has a triple threat if you will of health information technology grants. One is that laying down on the highway, which is a health information exchange. And that will go online in the next year that will allow us to share what information we collect at the points of care. We have a regional extension center grant, which is designed to help and encourage providers to take up electronic medical records to achieve meaningful use, and then we finally had this Beacon Community grant that is designed to get everyone not just to collect the information and use it at the point of care, see that it moves across the system that we're using that data in a focused way to improve the quality of care for a population. This is across providers. And so those big set of grants bring the community and the Quality Forum and others together to focus on the energy and efforts of making not just the electronic medical record in place but make it actually a tool to improve quality and cost-effectiveness. What happened for our state is a couple of things. First is: the opportunity because of the loss of legacy systems and because of, frankly, I think the kinds of providers that came in or stayed after the storm, not just in New Orleans. In all of south Louisiana we had two major storms that were pretty disruptive, and those kind of early adopters—physicians who were accustomed to change—were pretty agreeable with the uptake of electronic medical records. Management clearly saw that we needed to implement that, and that it was going to be necessary to allow us to make the maximal use of funding that we had to support primary care and also to do the most for the population. And it became part of our culture very quickly, and patients began to expect it. Where we needed to get over the hump was—especially in other parts of the state—was with the support of programs like meaningful use, which then lead to payment through Medicaid, Medicare and hopefully, eventually, from other payers. That certainly helps providers to recoup their costs. We've had, because of all the uptake in this community, for example, there's a lot of physician-to-physician support and hospital-to-hospital support that has allowed mentorship and networking around the idea.
Andis Robeznieks: OK, thank you. And we've also received several questions as you might expect about return on investment in the IT systems and the medical home model itself, and I was just wondering if each of you could perhaps break down what you've seen. And we can begin with Dr. King.
Jim King: Well, when we first set up our practice in 2004 with electronic health records, a couple of things happened as we did that. Productivity went down. There was a learning curve on how to use the equipment, and at the same time, the cost of adding the electronic health system, the EHR, of course, added to expenses. So there was a negative for about the first six to nine months. Then as we learned how to use the system, after approximately a year everything leveled out from a cost—but the practice has to be able to get through that first year. And that's the main thing with stimulus money where you're meeting meaningful use, and doing those things, that helps beginning most practices with electronic health records will not make them more money but they definitely won't be a negative after a period of time as you improve the care. But, for us, the payments—we're working with Blue Cross Blue Shield here in Tennessee that are paying us added money as we develop the patient-centered medical home. Of course we're looking at other ways, too, to kind of help fray that earlier cost. But it is a significant cost at the beginning. Thank you.
Andis Robeznieks: Thank you. Dr. Stout?
Somava Stout: So there are actually the Patient Centered Primary Care Collaborative has recently put out a paper that looks at the cost effectiveness of a medical-home demonstration. And there's been a lot actually written about this, so I think what we've seen nationwide is that most practices are able to see in 18 months to two years a return—a real break-even point—and then after that, to see substantial return on investment in terms of cost savings. Of course that assumes that there's things like global payments increase to share those savings with a healthcare system that's doing that kind of innovation. It's been interesting to see that—for us the points that you have to get through that first year to two years is I think really important. When you start going on medical records, the thing is that you don't just do the things you did before, which is sort of document notes in there. You begin to use it as a way of doing population management in a whole bunch of other ways. And that really requires continued effort, optimization and development, and having support for this work is actually really, really crucial. I think they found that some of the key elements of IT that make a difference are improving connectivity between providers who otherwise might not easily be able to exchange information—whether it's mental health providers or specialists or emergency rooms—but also clinical-decision support not only for the physician but also for other members of the care team, so that when that patient comes in and they're overdue for things or when you go to prescribe something and you can look up what hospital drug interactions might be but also what recommended care might be, that these things make a big difference in health and improving costs. And I think—we think about electronic medical record as one thing. It's important to recognize that there's actually a whole spectrum of what technology can do and our ability to effectively use technology to help us provide better care for patients but also to make strategic decisions that help us improve cost and quality I think are really important.
Andis Robeznieks: OK, and Dr. DeSalvo, this will be our last question. I was wondering if you could speak to, kind of, the return on staffing that might be required. You spoke about people practicing to the top of their license. And I was wondering if there is any kind of measureable return with the increased use of nurse practitioners and other physician expenders?
Karen DeSalvo: In this community to date in Louisiana, we have not looked at specifically the cost effectiveness or the return for individual members of the team. Part of the reason for that would be the teams themselves, the compositions, will vary from site to site, because they'll vary depending upon the population. So the team reflects the needs of the community that you're serving. As an example, where you may have a clinic that serves a much younger population and with more kids, you might have more services attuned to that. Where you have a more geriatric neighborhood, you might have a team more in line with that. We have, for example, a couple of the sites that have started through Tulane, one of them is downtown in a very urban environment with a lot of poverty, so that the team there does include nurse practitioners, includes social work, a legal aid clinic, community health workers, medical interpreters—mostly for Spanish—and a lot of outreach activity with the local churches and organizations. We have another clinic in New Orleans East that principally serves the Vietnamese population, also some Latinos. That population has a very strong social service infrastructure associated with their church and their community-development corps and neighborhood association, but we don't have a lot of wraparound stuff because it was already—and what we haven't already said was that an MOU between those organizations, that they work together. And the community health workers, as an example, work for the neighborhood association but are linked in with the medical home team so that the patients can enter the door of primary-care medical-home team through their neighborhood association, their CDC, not just through the primary-care site. So it does vary, I will say, specifically, almost impossible to tell what individual team members matter. What you can look at instead is the cost per person, and based on the first three years of what we did, it was in the neighborhood of about $460 a year for primary care on average per person, and that was through everything—not pharmacy benefits, not so much diagnostics but some basic labs. So relatively inexpensive or extremely inexpensive, quite frankly, but patients were, as I said earlier when I talked, reporting great quality care, and that's through external assessments. And we know that their experience was quite strong.
Andis Robeznieks: OK, well thank you very much. And I'd like to thank our panelist for staying on—Dr. Stout, Dr. King and Dr. DeSalvo. I'd also like to thank our audience for providing some very excellent questions.
Karen DeSalvo: Thank you for having me.
Somava Stout: Thank you.
Jim King: Thank you.
David May: Thank you. This concludes today's discussion on how to build a better medical home. For those who want to view the webcast again, all attendees will receive a follow-up e-mail with a link to the recording of this webcast available on ModernHealthcare.com/webinars. All slides presented during this webcast are also available at that address. We thank you.