Building an Integrated System for
Personalizing Care
Tim Johnson, MD
Spring, 2014
Intermountain Medical Group
• 1,056 physicians
• 342 primary care
• 491 secondary care
• 86 hospitalists
• 17 radiologists
• 120 urgent care
• 265 advanced practice clinicians
• 81 primary care clinics
Dual Model for the Medical Home
Distributed Model
Intensive Model
Distributed Model: Personalized Primary Care
Intermountain Medical Group and SelectHealth
Modeled on 2011 PCMH NCQA Standards
Team members
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Primary Care Clinician
•
RN Care Manager
•
MA Health Advocate(s)
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Advanced Practice Clinicians
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Doctor of Pharmacy
•
Mental Health Integration
Personalized Primary Care
Implementation 2010 - 2014
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•
•
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64 adult primary care clinics
17 pediatric clinics
345 physicians and advance
practice clinicians
~100 care managers and health
advocates
Hybrid model: central and region
leadership
Level 2 and level 3 within 2-3 years
Personalized Primary Care: Results
Allowed Per Member Per Month
PPCs
All
Clinical
Quality
20%
Total Cost
Trend*
1
2
3
Years after Implementation
64%
62%
60%
58%
56%
54%
52%
50%
48%
Intermountain diabetes bundle:
 HgbA1c < 8%
 LDL < 100
 BP < 140/90
 Annual nephropathy screen
 Eye exam every 2 years
35%
2013 Stretch Goal
Patient
Satisfaction
*Preliminary results, risk-adjusted and normalized for contractual payment differences
Intensive Model: Personalized Care Clinic
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An outpatient clinic that provides
intensive medical, behavioral, and
social management for
Intermountain’s high-risk patients
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Patients in the top 5-10% of costs
for 2 of the last 3 years
Personalized Care Clinic: The Team
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•
•
•
•
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Internal Medicine Physician
Palliative Care Physician (0.2)
RN Care Manager
Psychiatry APRN
LCSW
Pharmacist
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•
•
•
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2 Medical Assistants
PSR
Clinic Manager
Assistant Region Operations
Officer
Region Medical Director
Personalized Care Clinic: Process of care
•
Acts like a primary care office with more resources to coordinate care,
address mental health conditions, and manage complex medication issues
•
Ensure patients receive care in appropriate setting – focus on acute care
utilization
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Coordinate and collaborate with all of the patient’s specialists
•
Committed to eliminating all avoidable health care emergencies
Your comments and questions…