Whats Needed In Primary Care? J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community.

What’s Needed In Primary Care?What’s Needed In Primary Care?

J. Lloyd Michener, MD

Professor and Chair

Department of Community and Family Medicine

Director, Duke Center for Community Research

Bridging the Chasm

Health Level Seven

April 20, 2009

Washington, DC

Twenty years of experience trying to improve Twenty years of experience trying to improve outcomes and lower costs for diverse communities in outcomes and lower costs for diverse communities in

North CarolinaNorth Carolina

Community Care PartnersCommunity Care Partners 42,000 Medicaid patients, Durham (NPCCN), Vance, Granville, Warren, Person, and Franklin Counties in 34 primary care practices Primarily women and children, largely African-American, growing Latino population Teams of community health workers, DSS social workers, nurses work with patients at home Offer patient education, patient support, system navigation, and self-management skill training Electronically linked between practices, hospitals, DSS, Health Depts., and the teams

Clinical Outcomes (State):Clinical Outcomes (State):• 34% lower hospital admission rates34% lower hospital admission rates• 8% lower ED rate8% lower ED rate

Financial Outcomes (State):Financial Outcomes (State):• 24% lower average episode cost for 24% lower average episode cost for children ($687 v $853)children ($687 v $853)• $3.5 million/yr for asthma management$3.5 million/yr for asthma management• $2.1 million/yr for diabetes management$2.1 million/yr for diabetes management• $60 million in SFY03$60 million in SFY03• $124 million in SFY04$124 million in SFY04TotalTotal::

Walltown and Lyon Park ClinicsWalltown and Lyon Park Clinics

Duke-Durham Neighborhood Partnership:Duke-Durham Neighborhood Partnership:• Neighborhoods ask for access to careNeighborhoods ask for access to care• Population: African-American, new Latino population, Population: African-American, new Latino population,

low-income, transient, uninsuredlow-income, transient, uninsured• Health characteristics: high ED use; inconsistent Health characteristics: high ED use; inconsistent

primary care, high risk health behaviors; substance primary care, high risk health behaviors; substance abuse; depression/anxietyabuse; depression/anxiety

• 70% of visits are return visits (continuity)70% of visits are return visits (continuity)• 37% of patients surveyed would have gone to ED37% of patients surveyed would have gone to ED• High patient satisfaction – 4.7/5.0High patient satisfaction – 4.7/5.0

Since 2000, serving 350 patients, average age 70 Since 2000, serving 350 patients, average age 70

who have multiple chronic conditionswho have multiple chronic conditions

44% have mental illness44% have mental illness All are home boundAll are home bound 84% are African-American; many with low to no 84% are African-American; many with low to no

family supportfamily support Low literacy; illiterate Low literacy; illiterate

Just for UsJust for Us

Community Partners:Community Partners:City of Durham, Housing AuthorityCity of Durham, Housing AuthorityLincoln Community Health CenterLincoln Community Health CenterDurham Council on SeniorsDurham Council on SeniorsArea Mental Health AgencyArea Mental Health AgencyDurham County Health DepartmentDurham County Health DepartmentDurham County Department of Social ServicesDurham County Department of Social Services

Practice Partners:Practice Partners:Duke CFM, SON, DUH, DRH, Center for Aging, Duke CFM, SON, DUH, DRH, Center for Aging, Department of PsychiatryDepartment of Psychiatry

All patients with hypertension 79% ≤ 140/90All patients with hypertension 79% ≤ 140/90Diabetics with hypertensionDiabetics with hypertension 84% ≤ 140/90 84% ≤ 140/90

OutcomesOutcomesAmbulance costsAmbulance costs ↓ 49%↓ 49%ER costsER costs ↓ 41%↓ 41%Inpatient costsInpatient costs ↓ 68%↓ 68%Prescription costsPrescription costs ↑ 25%↑ 25%Home health costsHome health costs ↑ 52%↑ 52%

Community RedesignCommunity Redesign

Durham Health Innovations (DHI): Durham Health Innovations (DHI): City of Medicine/Community of Health City of Medicine/Community of Health

Key points:Key points: Grants are for planningGrants are for planning Relationships and teamworkRelationships and teamwork Improve the health of our communityImprove the health of our community Work with the DCCR Team and additional resourcesWork with the DCCR Team and additional resources This is a collaborative process – we will work together, This is a collaborative process – we will work together,

learn together, and succeed togetherlearn together, and succeed together

Proposals…Proposals…

1.1. Adolescent HealthAdolescent Health

2.2. Asthma / COPDAsthma / COPD

3.3. CancerCancer

4.4. Cardiovascular Disease/CKDCardiovascular Disease/CKD

5.5. DiabetesDiabetes

6.6. HIV/AIDS, STDs, HepatitisHIV/AIDS, STDs, Hepatitis

7.7. Maternal HealthMaternal Health

8.8. Obesity Obesity

9.9. Obesity & WellnessObesity & Wellness

10.10. Pain ManagementPain Management

11.11. Substance AbuseSubstance Abuse

12.12. Seniors HealthSeniors Health

Medical Home Version 1Focus: Improved outcomes for patients seen in officeCare Location: Offices and hospitalsIT: MinimalProvider: Physicians and Office team

IT

Office

Anywhere

Office Team

Community Team

Patients

Physicians

Hospital

Example: Duke Family Medicine, Duke Primary Care, General Peds, Duke Outpatient Clinic

Medical Home Version 2 – Our Current State: What do We Medical Home Version 2 – Our Current State: What do We Have and What do We Still Need to Do?Have and What do We Still Need to Do?

IT

Office

Anywhere

Office Team

Community Team

Patients

Physicians

Hospital

Communication Tools • Telephone • Email • Text messages• Kiosks• Patient Portal

Care Management Tools • Risk assessment• Data surveillance • Care plans• CMA/CHW• Group visits

Community Partners/Sites• Neighborhood care • Patient surveillance • Point of care testing• Neighborhood nurses• Medication access

Focus: Improved outcomes for patients seen across the spectrum of careFocus: Improved outcomes for patients seen across the spectrum of careCare Location: Offices and hospitalsCare Location: Offices and hospitalsIT: Somewhat integratedIT: Somewhat integratedProvider: Physicians, Office team, and Community teamProvider: Physicians, Office team, and Community team

Medical Home Version 3 – Connected CareMedical Home Version 3 – Connected Care

IT

Office

Anywhere

Office Team

Community Team

Patients

Physicians

Hospital

Focus: Improved outcomes for allFocus: Improved outcomes for allCare Location: AnywhereCare Location: AnywhereIT: Highly integratedIT: Highly integratedProvider: NetworkProvider: Network

IT for Primary CareIT for Primary CareWhat’s Needed?What’s Needed?

1.1. Shared patient data repository across Shared patient data repository across community partnerscommunity partnersPrototype solution – COACH/NPCCNPrototype solution – COACH/NPCCN

Network PartnersNetwork Partners

2 Care Management Teams2 Care Management Teams 34 Primary Care Clinics (FM, IM, Peds, Ob-Gyn, 34 Primary Care Clinics (FM, IM, Peds, Ob-Gyn,

FQHC)FQHC) 3 Urgent Care Facilities 3 Urgent Care Facilities 5 Hospitals and Emergency Depts.5 Hospitals and Emergency Depts. 8 Government Agencies (HD, DSS)8 Government Agencies (HD, DSS)

HL7 DSS – Architectural OverviewHL7 DSS – Architectural Overview

Decision Support Service

Decision Support Service

Knowledge Modules

Knowledge Modules

Institution A Institution A

Client Decision Support Apps

Client Decision Support Apps

Patient Data Sources

Patient Data Sources

Queries for required ptdata

Queries for required ptdata

Institution B Institution B

Client Decision Support Apps

Client Decision Support Apps

Patient Data Sources

Patient Data Sources

Queries for required ptdata

Queries for required ptdata

Conclusions about patientConclusions about patient

Patient data, knowledge modules to use

Patient data, knowledge modules to use

©2009 Kensaku Kawamoto©2009 Kensaku Kawamoto

Trigger

HL7 DSS StandardHL7 DSS Standard

Trigger

COACH HIE ContextCOACH HIE Context

Enables Population Health Management model of care Enables Population Health Management model of care Supports care management activities (documentation, Supports care management activities (documentation,

communication, referrals, care plans, etc.)communication, referrals, care plans, etc.) Receives and displays external billing/claims/clinical data from 5 Receives and displays external billing/claims/clinical data from 5

hospitals, 8 clinics and NC State Medicaidhospitals, 8 clinics and NC State Medicaid 6 Counties => 40,000 Medicaid Beneficiaries6 Counties => 40,000 Medicaid Beneficiaries Centralized data repositoryCentralized data repository

2.2. Systems to support population health Systems to support population health managementmanagementPrototype solution – COACH population health Prototype solution – COACH population health

management system for NPCCNmanagement system for NPCCN

CDS RepositoryCDS Repository

HL7HL7Decision Support Decision Support

ServiceService

COACH Sample ScreenCOACH Sample Screen

Sample Provider NoticeSample Provider Notice

©2009 David F. Lobach©2009 David F. Lobach

3.3. Tools to support efficient point-of-care Tools to support efficient point-of-care decision making regarding health decision making regarding health maintenance maintenance Prototype solution – eBrowser disease Prototype solution – eBrowser disease

management dashboard management dashboard

Duke eBrowser – Disease Management Module

© 2007 David F. Lobach

4.4. Ability to identify clinic and provider level Ability to identify clinic and provider level performance on care quality metricsperformance on care quality metricsPrototype solution – DHTS care quality reports Prototype solution – DHTS care quality reports

powered by CDR, DSR, and SEBASTIANpowered by CDR, DSR, and SEBASTIAN

Duke Health Disease Management System – Reporting for Diabetes

© 2009 David F. Lobach

Outstanding ChallengesOutstanding Challenges

Data standards (e.g., HL7 version 3 standards) are too Data standards (e.g., HL7 version 3 standards) are too complex and costly to routinely implementcomplex and costly to routinely implement

Lack of incentives to share dataLack of incentives to share data Training on data collection and data entryTraining on data collection and data entry