U.S. Health Care Great Skills Great Science Poor Integration / - - PowerPoint PPT Presentation

1

Marjie Harbrecht, MD Chief Executive Officer

Won’t You Be My Neighbor?

400-526707

U.S. Health Care

• Great Skills
• Great Science
• Poor Integration / Coordination
• Fragmented - Silos
• Misaligned Incentives
• Culture

PCPs - Raise Your Hand if these issues are common in your practice

• 1. You don’t know the specialist you’re referring patients to
• 2. Specialists say they don’t get needed information
• 3. Patients complain specialist didn’t know why s/he was

there

• 4. Tests you’ve already performed are duplicated
• 5. You don’t hear back from a specialist after a consultation
• 6. A referral doesn’t answer your question
• 7. Your patient doesn’t come back to see you after a

consultation or is referred to another specialist

• 8. You are unaware that your patient was seen in the ER/

Hospital.

Specialists - Raise your hand if these have occurred in your practice:

• 1. You don’t know the provider that referred the patient
• 2. You aren’t clear what question you’re supposed to be

answering.

• 3. The patient doesn’t know why s/he was there.
• 4. You don’t get sufficient information with the referral –

(i.e., pertinent history, workup done, etc)

• 5. You can’t access results from tests already performed.
• 6. You don’t get follow up on a patient you were

concerned about.

You’re Not Alone!

• PCPs report sending information 70% of time; specialists

report receiving it 35% of the time1 and 68% of specialists reported receiving no information from pcp prior to referral visits

• Specialists report sending a report 81% of the time;

PCPs report receiving it 62% of the time1

• 28% of primary care and 43% of specialists are

dissatisfied with the information they receive from each other (Gandi et. al. J Gen. Int. Med. 2000)

1 O’Malley, A.S., Reschovsky, J.D. (2011) Referral and consultation communication between primary care and specialist

physicians: finding common ground. Arch Intern Med, 171 (1), 56-65.

Patient Reports for Poor Coordination

Nearly Half Report Failures to Coordinate Care

Percent U.S. adults reported in past two years:

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.

No one contacted you about test results,

• r you had to call repeatedly to get

results Test results/medical records were not available at the time of appointment Primary care doctor did not receive a report back from a specialist

Any of the above 25 21 19 15 13 47

20 40 60 Doctors failed to provide important medical information to other doctors or nurses you think should have it Specialist did not receive basic medical information from primary care doctor

Why Make Care Coordination A Priority?

• Patients and families hate that we can’t make

this work.

• Multiple care plans - conflicting information
• Poor hand-offs lead to delays/confusion -

patient safety issues

• Enormous waste from unnecessary referrals

and duplicate testing

• It will make all of our work more effective
• Everyone will be happier!

Source: Ed Wagner, MD – MacColl Institute

As The Environment Swirls Around Us…

Push for Integration

• Market Consolidation
• Hospitals buying physicians
• Large physician groups forming
• Integrated systems growing
• Regardless of where you end up, this

work needs to be done!

10

Fear – Skepticism - Old Baggage?

• How will this effect my income?
• Is this managed care in drag?
• Is this a plan to decrease referrals?
• Will I get dumped on with all the hard patients?
• “Things are just fine the way they are….”

Déjà vu… All Over Again?

• What’s different from Managed Care days?
• Practice and community redesign
• No-one taught us how before
• Gatekeeper to Gateway
• Better tools (Technology) to coordinate care
• Patient sophistication and engagement
• Aligning incentives for ALL to work together
• Quality + Affordability + Experience
• Realization that no one can do this alone!

12

When Teams Don’t Work Well…

13

U.S. Men's Basketball Falls Flat on World Stage By David DuPree, USA TODAY August 15, 2004

ATHENS- “This is the Olympics, and the U.S. men's basketball team was rocked, shocked, humiliated and exposed on sports biggest stage Sunday as Puerto Rico, a Commonwealth of 4 million residents, pulled off the upset of all Olympic upsets with a 92-73 drubbing of the Americans.”

Most SKILLED players in the world - What went wrong??

GREAT PLAYERS vs. GREAT TEAM

Individual Choice VS Team Efficiency

Team Work??

When Teams Work Well…

17

The Achievements Of An Organization Are The Results Of The Combined Efforts Of Each Individual

• -Vince Lombardi

20

Some Reasons Why This Ain’t Easy

• The typical primary care physician has 229
• ther physicians working in 117 practices with

which care must be coordinated.

Pham et. al Ann Int Med. 2009

• In the Medicare population, the average

beneficiary sees seven different physicians and fills upwards of 20 prescriptions per year

Partnership for Solutions, Johns Hopkins Univ. 2002

No Systems

Misaligned Incentives Culture - It’s Just Not Important

Sorry, No time

I’m not paid to do this!

Ideal State

• Shared “community” vision
• Shared data – timely, actionable, in usable format
• All patient information available at point of care
• List of those needing services - for outreach
• Aggregated across community to identify target areas

for improvement and monitor progress

• Shared Care Plans
• Everyone that touches patient on the same page…

including the patient/family

23

24

Integrated Community Care (Accountable Care Organizations)

Provided Courtesy of Premier Healthcare Alliance

Ultimately, working together to assist patients in achieving the highest level of health they can, preventing problems BEFORE they occur!

25

27

First Step: Create A Shared Vision

The Discussion

• Mutual respect of what each brings to the table
• Recognition of the value of role differentiation
• Appreciation of primary care as foundation (“quarterback”)
• Specialty skill sets as important and complimentary
• Acknowledgement of a flawed system
• Longing for more “professionalism”
• Better communication, consideration, cooperation and integration
• Always return to: Patient Centered Care

Identify Pain Points – Work Toward Solutions and Common Goals Solutions

• Many misconceptions & wrong assumptions
• PCP thought it best to make the appt for patient but

specialist knew that was associated with high No Show rate.

• Specialist thought they were helping by referring on

to another…..

• Beware of the powerful lure of status quo

PCMH-Neighbor Model - Framework

Patient-Centered Medical Home (PCMH)

An approach to providing high-quality, safe, continuous, coordinated, comprehensive care, with a partnership between patients and their personal health care team… (“The Quarterback”)

31

“Won’t You Be My Neighbor?”

Medical Neighbor (PCMH-N)

A clinician that collaborates with a PCMH or another medical neighbor to participate in the care team to enhance bi-directional communication and collaboration on behalf

• f the patient.

32

Integrated Co-located Referral based

Key Elements

Patient-Centered extension of team care (team members working for what is best for the patient)

Keep fluid (dynamic) to adapt to changes in patient or disease status

33

• Access – appropriate and timely consultations
• Coordination
• Define roles - clarify who’s doing what?
• Clear Communication
• Define expectations
• Ensure effective flow of information - pre/post referral
• Ensure ALL understand, including patients/caregivers

Otherwise Stated:

A framework so that patients neither fall through the cracks nor get duplicated services Safe – Effective – Efficient

31 30 49 53 32 25 36 32 20 15 33 41 49 57 59 42 41 51 42 30 33 54 20 40 60 80 100 AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Medical home No medical home

35

Coordination Gaps With and Without Medical Homes in Past 2 Years

Percent*

Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Examples of Agreements/Checklists

36

American College of Physicians (ACP)

Carol Greenlee MD FACP FACE Neil Kirschner, PhD

www.acponline.org Systems of Care Workbook

Scott Hammond, MD

Models for Establishing Agreements/Compacts

• One-on-one
• System-wide “adoption” (all players)
• Unilateral approach
• Medical Center / Specialty Practice (“this is how we agree to work

with those who refer to our center/practice”)

38

NCQA’s Specialty Practice Recognition 2013 ~ Draft Standards ~ October 2012

NCQA’s Specialty Practice Recognition 2013

Release date: March 2013 Applications accepted: June 2013

Prepared Patient

Patient aware of and in agreement with referral with appropriate expectations

Patient Wallet Card

40

Can This Really Happen?

41

Population Health Experience

• f Care

Per Capita Cost

The Triple Aim

By The Institute for Healthcare Improvement

43