1. The Medical Home in Residency: Comparison with a Non-Residency Setting Group Health Family Medicine Residency Seattle Sara Thompson, MD - Program Director Carl Morris, MD - Associate Program Director

2. Outline PCMH Background Group Health’s Medical Home Group Health Residency’s Medical Home Outcome Next steps Discussion

3. 3 Medical Home – A Brief Historic Review Started in pediatrics – initially in the1960’s, expanded in 2002 2004 Future of Family Medicine 2006 ACP 2007 Joint principles of the patient-centered medical home from AAFP, AAP, ACP and AOA NCQA P4 (Preparing the Personal Physician for Practice) – 6 year, 14-residency project with each residency incorporating some aspect of the medical home TransforMed - National Demonstration Project with 36 clinical practices

4. 4 2007 Joint Principles of the PCMH Personal physician Physician-directed practice Whole person orientation Coordinated and integrated care Quality and safety Enhanced access Payment reform

5. 5 Group Health – a Brief Introduction Integrated staff model HMO in Washington and western Idaho established in the 1940s > 500,000 patients 26 primary care clinics: 81% FPs, 4% internists, 15% pediatricians 4 specialty clinics, 6 UC/ER, 7 hospitals (contracted) Pharmacy and lab integrated EMR Guidelines, patient registries Consulting nurse (24/7)

6. 6 The Group Health Medical Home: Background 2002-2006 a series of reforms including –Same day appointing (open access) –Implementation of a new EMR (EPIC) –Online patient access (email to provider, labs, record)

7. 7 The Group Health Medical Home: Background Results –Improved patient access/satisfaction –Increased MD workload –Decreased MD satisfaction –Increased utilization: ER, specialty, hospital –Reductions in quality of care

8. Houston, we have a problem 8

9. 9 The Group Health Medical Home: Problems and a Proposal The Problems: –Physicians were burned out –Many planned early retirements –It was difficult to find new recruits Proposal from the Medical Director: –Medical Home Pilot

10. 10 The Group Health Medical Home: Core Principles Relationship to provider is core Physician leads the clinical care Care is comprehensive Patient-centered access: 24/7, electronic Align clinical and business systems

11. 11 The Group Health Medical Home: The Pilot Project Changes: Structural Point of care Patient outreach Management structure/philosophy

12. 12 The Group Health Medical Home: Pilot Project Structural changes –Decrease patient panels (from 2300 to 1800) –Longer visits (30 not 20 min) –Dedicated “desktop medicine time” –Automated phone call routing

13. The New Schedule

14. 14 The Group Health Medical Home: Pilot Project Point of care changes –Promotion of web portal functions (pharmacy refills, secure messaging, medical information) –Pre-visit chart review –After visit summaries at end of visit

15. Pre-visit Work: The PCER (Patient Care Exception Report)

16. Pre-visit Work: Done Prior to the Visit by the MA

17. 17 The Group Health Medical Home: Pilot Project Patient outreach changes –New patient outreach –Chronic disease medication –Birthday reminder care letters –Outreach using deficiency reports (for both chronic conditions and health maintenance)

18. 18 The Group Health Medical Home: Pilot Project Management changes –Daily team huddles –Visual reporting systems to track changes –Rapid process improvement cycles –Lean philosophy: the front line is where the knowledge lies

19. The Huddle Communication with the team Review access and performance targets Structure has evolved over time

20. Daily Tracking: Visual Report on Access

21. Weekly Report: Visual Report on Clinic Visits, Phone and e-Visits (and Targets)

22. 22 The Group Health Medical Home: Outcome – Year One Cost neutral Improved patient satisfaction Improved quality of care (HEDIS) measures Improved provider satisfaction Reid RJ, Fishman PA, Yu et al. Am J ManagCare 2009:15(90):e71-e87

23. The Group Health Medical Home: Outcome – Year Two Continued improvement in –Patient satisfaction –Quality –Physician satisfaction (decrease in burnout) Cost savings –6% fewer hospitalizations –29% fewer ER visits Reid et al. The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, and Less Burnout for Providers. Health Affairs. 2010; 29(5):835-843

24. The Residency Medical Home

25. 25 GH Residency Medical Home: What Makes a Residency Different? Unique Characteristics Dual Mission of Teaching and Patient Care Training Residents Complexity working in a large organization Rules and regulations Inefficiencies

26. GH Residency Medical Home: Implementation Training Residents Introduction to concepts of the medical home early and often (didactics, business meetings) Increased involvement of support staff as teachers Early 1:1 chairsides with faculty 26

27. GH Residency Medical Home: Implementation Training Residents Acknowledgement of need to prepare for a new model of care: virtual visits are a part of training! –Training for phone visit and electronic visit content and documentation –Process for evaluation and review of secure messages Regular time to review guidelines and registry data with planned outreach 27

28. GH Residency Medical Home: Implementation Multiple providers Huddles at the beginning of each clinic Involve support staff ACTIVELY in all change Identify teams (providers and support staff) Inbasket coverage: Teams cover, but much electronic work is done from off site by the primary care provider. 28

29. GH Residency Medical Home: Implementation Rules and Regulations RRC innovation proposal: credit for phone and secure messages (3 visits worth one face-to- face. 1400 visits, 750 virtual visits over 3 years) GH driven: Clinic template changes 29

30. The New Schedule

31. GH Residency Medical Home: Outcomes 31

32. GH Residency Medical Home: Outcomes Quality measures Patient satisfaction RRC Innovation Proposal accepted 32

33. GH Residency Medical Home: Outcomes: Quality Measures HEDIS scores –One year pre and post results –Remarkable changes in preventive and chronic disease measures 33

34. 2009-2010 HEDIS Measures Mar 09Mar 10Trend ABX Adult Acute Bronchitis65.4%36.4% 29.0% Well-Child 3-6 YO50.0%75.0% 25.0% Screen: Colorectal Cancer (NEW)38.3%60.1% 21.8% Postpartum Care56.7%78.2% 21.5% DM: HbA1c>9.051.5%32.5% 19.0% ASA: Ace for CAD63.0%75.6% 12.6% DM: HbA1c Test78.8%88.3% 9.5% Well-Care Adolescent27.3%36.1% 8.8% ASA: Ace for DM68.4%75.4% 6.9% IET: Engagement9.8%16.7% 6.9% Screen: Breast Cancer Total50.3%56.1% 5.9% DM: BP <140/9054.5%59.7% 5.2% CAD: Chol Mgt-LDL Screen85.7%90.0% 4.3% DM: LDL Screen72.7%76.6% 3.9% ASA: Statin for CAD77.8%80.5% 2.7% Prenatal Care83.3%85.9% 2.6% High Blood Pressure50.6%52.4% 1.8% Screen: Cervical Cancer75.5%76.9% 1.3% Asthma Appropriate Meds83.3%84.6% 1.3%

38. GH Residency Medical Home: Outcomes: Patient Satisfaction Patient Satisfaction –One year pre and post results –Improvement in all categories 38

39. Patient Satisfaction

40. GH Residency Medical Home: Next Steps Curriculum revision –More consistent time in clinic –More explicit training in e-visits Chronic Disease Management (TIC sessions) Continuous improvement –Use of data 40

41. 41 Discussion How might this work in other programs Opportunities Possible barriers and pitfalls