Transforming Primary Care:
What Works and What’s Next
A chartbook created by the staff of
Improving Chronic Illness Care
At the MacColl Institute for Healthcare Innovation
Group Health Research Institute
Supported by The Robert Wood Johnson Foundation
Grant # 053022
I. Primary care in crisis
2
Changing demography and
practice content
Substantial proportion of ambulatory visits among adults are
for chronic illness management1
Chronic problem—
routine
Chronic problem—
flare-up
All patients
30%
9%
Age 25-44
26%
9%
Age 45-64
37%
10%
Age 65+
42%
11%
Note: See slide notes for citations in this chartbook or the CD’s Articles & Websites
section.
3
Greater care complexity
• Studies2,3 estimate that it would take 7.4 hours to
deliver all recommended preventive services and 10.6
hours per working day to deliver all evidence-based
care for chronic conditions to a primary care panel.
• “These excessive demands contribute to long waiting
times and inadequate quality of care for patients.”4
• Concern about one’s ability to manage complex,
chronically ill patients may contribute to driving career
choice away from primary care.
4
Quality of current primary care
• Patients with major chronic illnesses receive recommended care
about half of the time.5
• Half of patients leave the doctor’s office without understanding what
their physician said.6,7
• These deficits are now perceived by patients, physicians
and policymakers.8
People with chronic
conditions usually receive
adequate medical care
5
Public
Physicians
Policymakers
48%
45%
22%
The physician workforce in decline
• The proportion of Internal Medicine residents
becoming generalists declined from 55% to 2%
within a decade.9
• Income, debt and work hours are all cited as factors.
6
A need for major healthcare reform
Do primary care physicians (PCPs) in the U.S. and
elsewhere see the need for major healthcare reform?10
Percent saying
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
Only minor
changes are
needed
23
33
41
18
38
60
42
56
37
47
17
Fundamental
changes are
needed
71
62
53
51
58
37
57
40
54
50
67
System needs
to be
completely
rebuilt
6
4
6
31
4
1
1
2
7
3
15
7
Primary care’s decline: Does it matter?
• The vast majority of the population prefers a PCP,
while 95% of Americans want one practice and/or
clinic where doctors and nurses know you, provide and
coordinate the care that you need.11
• Countries with better primary care have better
health outcomes.12
• U.S. states with higher primary care/population ratios
have reduced costs and better quality healthcare.13
8
And how will we pay for healthcare?
• The U.S. is currently spending 17% of GDP, the most
of any nation.14
• If healthcare spending grows at the current rate, a
staggering 119% of the real increase in income over
the next eight decades will be consumed by healthcare
spending, leaving nothing for other needs.
9
What can we do?
• The future of primary care (and our healthcare system)
depends upon its ability to improve the quality and
efficiency of its care for the chronically ill.
• It will also require a recommitment of primary care to
meet the needs of patients for timely, patient-centered,
continuous and coordinated care.
• That will require a major transformation or redesign of
practice, not just better reimbursement.
• However, such transformations will be difficult to
motivate or sustain without payment reform.
10
II. What works
11
What works – Previous disks in this series
Volume 1: “Tackling the
Chronic Care Crisis”
explained the Chronic
Care Model (CCM) and
summarized the evidence
base that has developed
in the last decade.
12
What works – Previous disks in this series
Volume 2:
“It Takes A Region” examined
the developing evidence base
for regional healthcare
improvement and proposed a
framework to guide community
improvement efforts.
13
Leadership
What works: Other tools developed by ICIC
• Visit our website, www.improvingchroniccare.org to
learn more about the following tools:*
– We have a practice toolkit, available to download from our
website, that is a summary of our lessons learned and a
repository of useful tools.
– We also have a toolkit to provide busy clinical practices with a
set of tested resources and tools to share with patients and
families in the day-to-day management of chronic conditions.
14
* See the slide notes page for specific URLs.
Success factors
What qualities do practices with
improved outcomes share?
1.
Team care – Clinical tasks shared with
non-physician staff
2.
Information technology – Functions that support
healthcare planning and proactive, population
based care
3.
Planned care – Patient needs identified prior to
encounters and systematically addressed
4.
Self-management support – Engaging patients as
partners in care
15
Successful care depends on
everyone on the team
For example: Depression Management
• Medical assistant administers PHQ-9
• MD diagnoses depression and initiates treatment
• Population manager enters patient and data in registry
• Care manager follows the patient over time provides
self-management support
• Consulting psychiatrist provides advice and care
manager and MD
16
Create a successful team
• Plan and improve care
together.
• Define roles and tasks
and distribute them
among team members.
• Train people for
their roles.
17
Incorporate improvement into daily work
• Meet briefly and often to review performance and plan
PDSA cycles.
• Make improvement a part of the clinical team’s
day-to-day thinking and work.
• Communicate regularly with senior leaders to discuss
successes and barriers.
18
Successful teams use a registry
For example: Most of the Medicare plans providing the best
diabetes care use a registry.15
Characteristic
High-performing
plans
Low-performing
plans
HbA1c >9.5
20%
49%
Use of a
registry
78%
40%
19
P
.02
Why is registry functionality so critical?
• Population management
– Allows practices to monitor entire practice panel and reach out
to those needing service.
• Encounter planning and reminders
– Easy access to data on guideline adherence and key indicators
facilitates productive interactions.
• Performance measurement
20
Successful teams support
self-management
• Organize and train team
members to provide basic
self-management support.
• Identify and use effective
self-management support
resources in their area.
• Make self-management
support a part of every
interaction.
21
Self-management support must include
key community resources
• Encourage patients to participate in effective
community programs that provide important services
(e.g. exercise, self-management support, smoking
cessation, peer support, etc.).
• Form partnerships with key community organizations to
support or develop programs.
22
What works
Organizational and environmental factors associated with
high-quality care
• Leadership — Leader attitudes about and level of support
for QI a strong predictor of success.
• Financing — Providing financial incentives for
transforming practice predicts involvement in QI and
perhaps success.
• Effective practice management systems — Must be in
place for practices to transform their clinical systems.
23
What works
Organizational and environmental factors associated with
high-quality care
• Trusted performance measurement is a powerful
motivator for practice involvement in QI.
• Networking smaller practices can provide leadership,
motivation and support for otherwise isolated practices
to engage in QI.
24
What works: Formal learning structures
like breakthrough series collaboratives
• Over the last decade we have
worked directly or indirectly with
over 1,500 practices in
collaboratives
• Teams that use PDSA cycles
based on the CCM systematically
over time:16
–
Usually see process improvement
–
May or may not see outcome
improvement
–
Enjoy their work more
25
Limitations of breakthrough series
collaboratives
Collaboratives have demonstrated positive change, but
there are limits:
• Small percentage of eligible practices participate —
usually early adopters
• Reach within a practice organization limited to the
most motivated
• Changes often made in ways that are
not sustainable
• Can encourage project-based
(i.e. time-limited) thinking
26
III. What’s next: The
promise and challenge of
the Patient-Centered
Medical Home (PCMH)
27
The CCM and the PCMH:
Complementary models
• Primary care is regarded as a linchpin to current
healthcare reform efforts.
• The PCMH is being proposed as a way to rejuvenate
primary care.
• The current PCMH model is a combination of the CCM
and the Pediatric Medical Home model.
28
Understanding the origin of the
Patient-Centered Medical Home
• The Pediatric Medical Home concept arose out of
frustration with the fragmented care of children with
special needs.
• Medical Home model puts the relationship with the PCP
and team at the center of a patient’s care, and makes
explicit the expectations of the PCP to provide timely,
continuous, patient-centered and coordinated care.
29
Understanding the origin of the
Patient-Centered Medical Home
• Both the PCMH and CCM rest on the clinical evidence
of practice changes that lead to improvements in
patient care and outcomes.
• Both models advocate that every healthcare
experience (e.g. visit, referral, admission, etc.)
connects the patient back to their PCP.
• Both emphasize and support the patient role in
decision-making and care.
30
Key features of a
Patient-Centered Medical Home17
•
Personal physician – First contact, continuous and comprehensive care
•
Team care – Collectively take responsibility for ongoing care
•
Whole person orientation – Take responsibility for all patient needs by
delivering or arranging care
•
Coordinated care – Across all elements of the healthcare system
•
Quality and safety – By implementation of CCM, continuous QI and
voluntary recognition process
•
Enhanced access – Via open scheduling, expanded hours and new
options for communication
•
Payment – Recognizes value of the PCMH, pays for coordination and
electronic communication with patients, and supports IT use
31
Is the Patient-Centered Medical Home
based on evidence?
• The CCM holds considerable evidence of salutary
effects on quality of care.16
• Improved continuity is associated with better
healthcare, patient satisfaction and outcomes.18
• Access and coordination are valued by patients, and
interventions directed at improving transitional care
have improved care and outcomes.19
32
What are the goals of the PCMH?
For long-term success and impact, PCMH
practices must:
1. Improve outcomes for patients with major chronic
illnesses.
2. Reduce costs through fewer emergency room visits
and hospitalizations (especially re-admissions and
admissions for ambulatory-sensitive conditions.
3. Improve both patient and provider experience.
33
Can these goals be achieved?
The Group Health PCMH Pilot20
• PCMH implemented in one primary care clinic with 10,000 patients
• Compared with two other clinics with similar baseline performance
• One year, in comparison with control clinics, the PCMH clinic
experienced:
– Greater improvement in patient experience
– Dramatic reductions in provider burnout and dissatisfaction
– Small improvements in clinical quality across the board
– Significant reductions in avoidable hospitalizations and emergency room
and urgent-care visits
– Improvements largely maintained in year two
34
What we are learning about implementing
the PCMH21
• Practice transformation requires “epic … redesign,” not just
incremental changes.
• Even in practices with EMRs, achieving “meaningful use” often
requires major educational and technologic intervention.
• Change fatigue is a serious concern.
• To make changes, practices need “adaptive reserve” —
leadership, QI time and solid relationships to weather the storm.
• Transformation is local; intervention ideas must be molded to fit
local environments.
35
What we still need to learn about the
elements of the PCMH model
• Practical approaches for making self-management
support a routine component of all transactions
with patients.
• How best to provide 24/7 access. Which coverage
alternatives best meet patient needs and reduce ER
and hospital use?
• How best to coordinate care and link to community
resources. Which alternatives best meet patient and
provider needs and reduce ER and hospital use?
36
What we still need to learn about
implementation
• Is there a best QI method to support PCMH implementation?
• Is there a best strategy for supporting practices involved in
PCMH implementation?
• What practice payment reforms best motivate engagement
in transformation?
• What practice payment reforms lead to the most successful
and sustainable implementation of the PCMH?
• How important is networking of smaller practices, and what
network structures are most successful?
• How do we best measure PCMH implementation
and effectiveness?
37
Transformation is a
Developmental Process21
• It begins with a solid core structure.
– Well-functioning clinical and QI teams
– Effective financial management
– Committed leadership
– Functional IT
• Develop or nurture the “adaptive reserve”.
• Try to change both the practice AND the environment in
which the practice operates (e.g. the medical
neighborhood).
– Have to address professional isolation and relationships between primary
and hospital/specialty care
– Try to address financial barriers and incentives
with payors
38
The structural barriers to overcome
becoming a medical home
• Difficulty defining the practice’s “panel”
• Lack of supportive information technology
• Lack of financial incentives
• Lack of hospital or specialist support of
care coordination
• Practice isolation from partners and QI infrastructure
39
A real opportunity
• There is real possibility of healthcare reform that
includes an emphasis on primary care renewal.
• There is strong support for a model (the PCMH) that
can improve healthcare and reduce costs.
• There is growing evidence and experience base for
transforming practice.
40
Thank you to The Robert Wood
Johnson Foundation and to all of our
partners in improving chronic care
over the last decade.
41
Continue to find us at:
www.improvingchroniccare.org
42