Build the proper structure Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of: Improve the patient.

A quick review of the IHI learning lab

Moving into the Medical Home

Building the PCMH From the Ground Up

Build the proper structure

Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of:◦ Improve the patient experience (satisfaction) ◦ Improve the health of the population ◦ Control or reduce cost

Then measure the outcomes

Using the Model to Get Broad Outcome Improvement

Identification and management of depression Management of care transitions Care coordination Team-based care Identification and management of socially

frail/ isolated individuals Pharmacologic management including

optimizing medication and dealing with adherence issues

Enhancement of the therapeutic environment

7 High Leverage Processes

Why it’s high leverage◦ Very high prevalence◦ Under diagnosed◦ Major gaps in care◦ Depressed individuals have more somatic

complaints◦ Chronic illness can produce depression◦ Depression as a comorbidity roughly doubles the

cost of the chronic illness

1. Depression

Using Technology◦ Identify high risk patients (multiple chronic

illnesses, multiple medications, unemployed, on disability…)

◦ Screening built into visits at regular intervals (e.g. PHQ2)

◦ Recall and tracking systems◦ Medication adherence tracking

Other resources◦ Community resources◦ On site integrated behavioral health (e.g.

counselors, CNS)◦ Liaison Psychiatrists and Psychologists

Depression

Why it’s high leverage◦ High risk situation for both quality and cost

outcomes◦ Patients and families experience considerable

anxiety and frustration at care transitions◦ Improving care transitions reduces the incidence

of hospitalizations and rehospitalizations

2. Care Transitions

Using Technology

◦ On demand medical records access Hospital portal ED and hospitalist access to PCP medical record

◦ Automated HIE All ED notes, H & P’s, consults, op reports, labs, and

imaging reports flow to EMR

Care Transitions

Why it’s high leverage

◦ Community care of North Carolina, Geisinger Health System, Kaiser, Group Health of Puget Sound, and Voice of Detroit Initiative have all reported positive outcomes using imbedded care coordinators

Care coordinators need to be part of the care team with a well defined specific role

◦ Remote third part care coordination and case management has been shown to not work as well

3. Imbedded Care Coordination and Case Management

Using Technology◦ Patient registries embedded in the EHR able to

identify specific populations With particular diagnoses With gaps in care Who are overdue for services Who are not at goal With high illness burden With limited social supports

◦ Measure overall practice or physician performance

◦ Benchmarking

Care Coordination

Why it’s high leverage

◦ MDs cannot provide all the care in the patient centered medical home model

◦ Consistent with the Chronic Care Model

◦ Improved quality and cost outcomes with team based care (Kaiser, Geisinger, Virginia Mason, CareOregon…)

4. Team Based Care

Key processes◦ Redefine roles and responsibilities including

integrating BH, SW… The work is done by more people but needs to be

coordinated◦ Internal communication gets more complex◦ Reframe patient expectations (this can be part of the

PCMH) discussion Technology support

◦ Internal messaging IMs, Texting…◦ Patient Portals◦ Shared care plans (ideally web based that can be

accessed by the entire care team)◦ As well as what has become the floor but needs some

refinishing CDSS, registries, and tracking systems

Team Based Care

Definition: combination of social isolation and low self esteem

Why it’s a high leverage process◦ Four times the cost of matched populations◦ Amenable to low cost interventions (brief

intervention with a counselor significantly improves outcomes) Support groups, case management, plug in to local

resources, pets…◦ Risk equivalent to smoking a pack of cigarettes

per day

5. Socially Frail Individual

Low self esteem- ◦ Question 6 on the PHQ9 are you feeling bad about yourself

or that you are a failure or that you let yourself or your family down.

Lubben Social Network Scale – 6◦ Family

How many relatives do you here from at least once a month? How many relatives do you feel at ease with that you can talk

about private matters? How many relatives do you feel close to such that you could

call on them for help?◦ Friendships

How many of your do you see or hear from at least once a month?

How many friends do you feel at ease with that you can talk about private matters?

How many friends do you feel close to such that you could call on them for help?

How to identify the socially frail individual?

Why it’s high leverage

◦ High prevalence of polypharmacy in patients with chronic illness Increased adverse drug events, drug-drug

interactions Issues of non-adherence, affordability, and patient

confusion Studies have shown decreased benefit when patients

are taking more than four medication

◦ Significant morbidity, mortality and cost associated with medication mismanagement

6. Medication Management

Key functions◦ Identify patients at risk due to polypharmacy and non-

adherence Manage out of pocket costs Address various contributors to non-adherence

◦ Medication reconciliation Technology infrastructure

◦ EHR drug-drug and drug-condition programs Formulary management programs Filled prescription information

◦ Portal◦ HIE

Brainstorming ideas:◦ Flash drives, medication reminder apps, blister packing

Medication Management

Why it’s a high leverage process.◦ Patients highly value the relationship with their

provider Continuity and the duration of the relationship correlate

with positive outcomes Patients want a care team who take the time to listen to

them and to know them as individuals The relationship often helps with patient activation

◦ Key functions Continuity Tracking patient preferences Access (visits, phone, e-mail…) Outreach Responsiveness Caring relationship

7. Enhancing the Therapeutic Environment

Technologic support◦ Secure messaging◦ Patient portal◦ Web-sites◦ Recall systems◦ Patient interaction with EHR◦ Use the EHR to track specific patient details

Enhancing the Therapeutic Environment

Superior clinical outcomes require investment in sustainable structures and processes

Medical homes can help achieve the goals of improving the patient experience, reducing costs, and improving population health

Focusing on highly leveraged processes and using technology are essential

Using technology thoughtfully is equally important

Summary