SLIDE 1
1
2
5 Domains of Hospital Care
Trauma and major acute illness such as
heart attacks and strokes
Minor acute illness Maternal and child care Chronic illness care Preventive services
Is Your Hospital a Patient Centered Medical Home? Joseph E. - - PDF document
Is Your Hospital a Patient Centered Medical Home? Joseph E. - - PDF document
Is Your Hospital a Patient Centered Medical Home? Joseph E. Scherger, MD, MPH We give you the care you want and need, how, when and where you want and need it Donald Berwick, MD 1 5 Domains of Hospital Care Trauma and major acute illness
SLIDE 2
SLIDE 3
3
A Patient Centered Philosophy
Focus on relationships, especially the
physician/patient relationship
Make the patient the center of care Provide accessible, comprehensive,
coordinated and continuous care
Make data understandable to the
patient
5 Features of a PCMH
Comprehensive Care – meet a patient’s physical
and mental healthcare needs as a team
Patient-centered Care – a partnership with deep
empathy for the uniqueness of patients
Coordinated Care –across all elements of the
healthcare system
Accessible services – minimizing delays and wait
times
Quality and Safety
SLIDE 4
4
Vital Components to Achieving The Goals of a PCMH
Health Information Technology – able to
store, manage and integrate patient information individually and as a population
Workforce – a team with the focus on
meeting all patient needs
Finance – aligned with the goals of the
- PCMH. Prepayment and hybrid payment
models with accountability for safety and quality
4 Transformations to a PCMH
Realize this is a marathon and takes time – a
two year transformation process
Become information centered through
robust technology with a patient portal to all records
Get patient feedback Consider the patient experience in all
locations
SLIDE 5
5
Physician Engagement is Critical
Connection with personal physicians is
the key to success
Physician referral is the most powerful
motivator
Integrated physician and self-care
critical for the outcomes
Taking Steps to a PCMH
Review and change operating
principles
Select care coordinators Seek recognition as a PCMH, e.g.
NCQA and JCAHO
Communicate with patients
SLIDE 6
6
Accountable Care Organizations (ACOs)
Systems that are accountable for the health of the population served by provided value driven health care - Committed to the Triple Aim
The Triple Aim
Improve the health of the population being
served
Improve the experience of receiving care Provide cost effective care – the value
equation – eliminate waste
SLIDE 7
7
The Triple Aim
Better Health Better Care Lower Cost
Main Features of an ACO
Manage cost and quality across a diverse
population with different payment systems
Sufficient infrastructure and management
acumen to support comprehensive care
Clear organization mission and commitment
to accountable population health care
Health Information Technology that enables
the achievement of ACO goals
SLIDE 8
8
Transforming Concepts for Success
Care becomes continuous access rather than
episodic
Care becomes proactive rather than reactive Patients become activated for self-
management
Care is delivered by highly organized teams
Effective ACOs are accomplished through effective PCMHs throughout the health system
SLIDE 9
9 58 y/o female with obesity and diabetes comes in with symptoms of fatigue, insomnia and back pain. She has a 15 minute appointment
HEDIS diabetes measures for this patient:
Percent with an annual retinal exam Percent with one of more glycohemoglobin tests Percent of those having glycohemoglobin tests showing a
level of <8.5 percent (goal <7.0)
Percent with an annual screening test for microalbuminuria Percent with two or more blood pressure checks per year Percent of those with one or more blood pressure checks
having a systolic BP <135 (goal <<130/80)
Percent with an annual lipid panel Percent of those with an annual lipid panel showing an
LDL level <130 mg/dL (goal << 100)
Case con’t
Other Diabetes Measures:
Flu vax Pneumovax Dental visit Cardiac screening test? Lab monitoring for side effects of meds Annual foot exam Baseline EKG?
SLIDE 10
10
Case con’t
Cancer Screening needs:
Colon- needs colonoscopy (or 3 other types
- f screening)
Cervical- needs pap if last <1-3 years prior Breast- needs annual mammogram
Osteoporosis screening and prevention Depression Screening and Management
Case con’t
General health issues: Adult Td Weight management Advance Directives/DPOA Culturally-sensitive care Patient Education for Self Management Tobacco Screen Alcohol screen Domestic violence screen What About her fatigue, insomnia and back pain?
SLIDE 11
11
Only 27% of hypertension is adequately controlled. 27% Only 26% of people with diabetes have blood pressures well controlled. 26% Only 25% of people with depression receive treatment. 25% 50% of patients hospitalized with congestive heart failure (CHF) are readmitted within 90 days. 50%
The Time Problem
Time Needed for Chronic
Illness Care
Time Needed for
Preventive Care
Time Needed for Acute
Care
Total face to face time for
2500 patients
Ann Fam Med 2005;3:209 Am J Pub Health 2003;93:635
10.6 hours a day for 2500
patients
7.4 hours a day 4.6 hours a day 22.6 hours/day
SLIDE 12
12
The Patient’s Life
6000 hours a year awake 1350 hours a year making decisions
important to diabetes
2 hours of episodic contact a year with
the primary care physician and only urgent access between
Improved Outcomes
Informed, Activated Patient
Productive Interactions
Prepared, Proactive Practice Team Resources and Policies
Community
Delivery System Design Decision Support Clinical Information Systems Self- Management Support
Health System
Health Care Organization
The Care Model
http://www.improvingchroniccare.org
SLIDE 13
13
Patient Activation and Self Management are a New Frontier in Medicine Made Possible by the Information Age
The Care Team Goes From Mandatory Caregiver to Advisor, Coach and Personal Resource
SLIDE 14
14
Give us control and we will use it, don’t and you will lose us
Google Rule # 1 from What Would Google Do? Jeff Jarvis
There is an inverse relationship between control and trust
Google Rule # 2
SLIDE 15
15
Soon many patients will control and guide their care. The care team will inform, coach and advise, but not be in control
Patient has a new diagnosis of Multiple Sclerosis. What is the most effective thing to do first?
1.
Ask her primary care physician to coordinate the care of the disease?
2.
Get treated by a local neurologist?
3.
Get treated by the region’s best expert in MS?
4.
Connect with a team to receive biopsychosocial care?
5.
Go to the internet and join the MS group in Patients Like Me?
SLIDE 16
16