1. The Doctor is In! Best Practices in Medical Home Journey Angelo P. Giardino, MD, PhD, MPH Medical Director Texas Children’s Health Plan Clinical Professor, Pediatrics Baylor College of Medicine

2. A discrepancy between what we know and how we practice  2003 RAND study “Half of patients don’t get right thing done” 55% “right things” done for preventive services 54% right things for acute care 56% for chronic care 79% for cataracts 11% for alcoholism McGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003; 348;26:2635-45. Quality Mismatch - Adults

3. Quality Mismatch - Children A discrepancy between what we know and how we practice  2007 RAND study “Half of patients don’t get right thing done” 47% “right things” done for indicated care 68% right things for acute care 54% for chronic care 41% for preventive 92% for upper respiratory tract infections 35% for preventive services for adolescents Mangione-Smith, R. et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 2007;357;15:1515-1523.

4. The Goal

5. A Team Approach To Care Shared Responsibility for Quality and Cost Fostering A Culture Of Improvement

6. Medical Home Capabilities Team approach to care Registries for the top few diagnoses Pro-active care coordination Quality systems and measurement built in Partnership with community resources Advanced patient education and self management support Service orientation Information technology support

7. Care Coordination Using the registry to assure that everyone on the list gets the indicated care on a timely basis This is a team responsibility not an FTE Arrange appointments, follow-up, lab and educational opportunities Standing orders

8. Quality Systems Built In Flow sheets, reminders and checklists Collect data for clinical measures at the time of care Use nationally endorsed measures Report the data for comparison purposes Use the data to drive process improvement in the office microsystem

9. Community Resources Disease specific educational or support services Engaging family and caregiver support Partnering with disease management programs provided by health plans Home care services when necessary

10. Time Spent on Care Coordination PCP <1% (87) Office Staff 15% (3118) Other 4% 756 Care Coordinators 76% (15,496) Social Worker 5% (951)

11. 0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 1900 1920 194019601980 2000 2004 From Overpeck (7) From AMA Total Physicians and FP/GP per 100,000 Population Total physicians FP/GP 300 From Silver (2) American Academy of Family Practitioners

12. 0 10 20 30 40 50 60 GP/FP GIM G Ped G Sur GOB Physicians per 100,000 Population — 2000 (Total MD’s) 0 0 - - 0-2,499 2,500- - 4,999 5,000- - 9,999 10,000- - 24,999 25,000- - 49,999 50,000- - 199,999 200,000- - 999,999 1,000,000- - 2,999,9993,000,000+ Physicians per 100,000 Population Size Of The Community Rural Small Town Suburban Urban American Academy of Family Practitioners

13. The Primary Care Physician Number of Office Visits to Primary Care Physicians vs. Other Specialists1 208 Million 146 Million 117 Million 471 Million 440 Million 23% 16% 13% 52% 48% American Academy of Family Practitioners

14. Characteristics of Practices in Transformation Successful Positive attitude True sense of team Process mapping Systematic approach All participate and are respected for their contribution Stuck in the mud Victim vocabulary Command and control Wondering why Just trying harder Physicians unapproachable American Academy of Family Practitioners

15. References McGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003; 348;26:2635-45. Mangione-Smith, R. et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 2007;357;15:1515-1523.