1. The Patient-Centered Medical Home: A Work in Progress Alliance for Health Reform Briefing Washington D.C. September 22, 2008 Diane R. Rittenhouse, MD, MPH Department of Family and Community Medicine Philip R. Lee Institute for Health Policy Studies Center for Excellence in Primary Care

2. The Patient-Centered Medical Home Model

3. Patient-Centered Medical Home 1. Personal Physician 2. Whole Person Orientation 3. Physician Directed Medical Practice 4. Care is Coordinated and/or Integrated 5. Quality and Safety 6. Enhanced Access 7. Payment Reform

4. Research Question To what extent is the medical practice infrastructure in place to support the implementation of the Patient Centered Medical Home?

5. National Study of Physician Organizations and the Care of Chronic Illness (NSPO) II Co-investigators: Stephen Shortell, PhD Lawrence Casalino, MD, PhD James Robinson, PhD Robin Gillies, PhD Funders: Robert Wood Johnson Foundation The Commonwealth Fund California HealthCare Foundation

6. National Study of Physician Organizations and the Care of Chronic Illness (NSPO) II  Compiled a list of all U.S. medical groups with 20 or more physicians n=1,520  35 minute phone survey with Medical Director or CEO  March 2006 – March 2007  60.3% response rate  n=339 physician groups  This analysis :  Limited to medical groups that treat all 4 chronic illnesses; excluded practices that said their physicians were “mainly specialists”  N=291 physician groups

7. Physician-Directed Medical Practice The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

8. Care is Coordinated and/or Integrated  Coordination and integration across the care continuum, including chronic illness care and prevention, facilitated by information technology  Examples:  Electronic patient registries  Electronic medical records  Electronic access to hospital, ED, specialist notes  Nurse care managers

9. Quality and Safety Emphasis on quality and safety: use of evidence-based decision support, performance feedback to physicians, active engagement in quality improvement activities, and a focus on pt experience Examples : Point of care decision support Performance feedback to physicians Participation in quality improvement collaboratives Incorporating patient feedback in CQI activities

10. Enhanced Access  Timely access to care and improved methods of communication between patient and the healthcare team  Examples:  Communication with patients by e-mail  Patient access to EMR on-line

11. Patient Centered Medical Home 20-Point Index

12. Patient Centered Medical Home 20-Point Index, by Medical Group Size

13. Lowest Performers, by Medical Group Size

14. Highest Performers, by Medical Group Size

15. Ownership

16. Summary: Medical Home Infrastructure  On average, the level of adoption of infrastructure components is low  Even among large integrated medical groups there is wide variation in medical practice across all domains (teams, coordination, quality, access)

17. Summary: Medical Home Infrastructure  The largest of the large groups are doing more  Groups owned by hospital or HMO are doing more

18. Patient-Centered Medical Home 1. Personal Physician 2. Whole Person Orientation 3. Physician Directed Medical Practice 4. Care is Coordinated and/or Integrated 5. Quality and Safety 6. Enhanced Access 7. Payment Reform

19. Patient-Centered Medical Home Personal Physician InfrastructurePayment

20. A Work in Progress