Introduction to Health Care and Public Health in the U.S. Evolution of and Trends in Health Care in the U.S. Welcome to Introduction to Health Care and Public Health in the U.S.: Evolution of and Trends in Health Care in the U.S. This is lecture d. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S. Lecture d This material (Comp 1 Unit 9) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Health IT Workforce Curriculum Version 4.0

Evolution of and Trends in Health Care in the U.S. Learning Objectives Describe the application of evidence-based medicine and clinical practice guidelines (Lecture a, b) Discuss quality indicators in medicine (Lecture c) Describe the patient-centered medical home and other models of care coordination (Lecture d) The learning objectives for this unit, the Evolution of and Trends in Health Care in the U.S., are to: Describe the application of evidence-based medicine and clinical practice guidelines; Discuss quality indicators in medicine; And, describe the patient-centered medical home and other models of care coordination.

History of the Medical Home Concept - 1 1967: American Academy of Pediatrics (AAP) introduced the medical home concept 2002: Expanded medical home concept to include specific characteristics of patient care This lecture will discuss the patient-centered medical home. The patient-centered medical home is a model of providing primary care that is comprehensive and takes into account the needs of the patient, as well as the clinician. The concept has been around for many years. In 1967, the American Academy of Pediatrics, or AAP, initially introduced the medical home concept as a central location to archive a child’s medical records. By 2002, the AAP expanded the medical home concept to include specific characteristics of patient care - that patient care should be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. Accessible Continuous Comprehensive Family-centered Coordinated Compassionate Culturally effective

History of the Medical Home Concept - 2 American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) have developed their own models for improving patient care AAFP: Medical home ACP: Advanced medical home Other organizations, such as the American Academy of Family Physicians, or AAFP, and the American College of Physicians, or ACP, have developed their own approaches for improving patient care. The AAFP calls it “the medical home model,” while the ACP calls it “the advanced medical home.”

The Patient-Centered Medical Home (PCMH) 2007 Joint principles of the patient-centered medical home delineated by: American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA) Approach to providing comprehensive primary care Health care setting that facilitates partnerships In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association, combined their efforts and drafted “The Joint Principles of the Patient-Centered Medical Home”, PCMH. They modeled the medical home as a method to provide comprehensive primary care for children, youth, and adults. They felt that the patient-centered medical home was a health care setting that would facilitate partnerships between individual patients, their physicians, and when appropriate, the patient’s family.

Personal Physician, Directed Medical Practice Personal physician: Each patient has an ongoing relationship with a personal physician Physician directed medical practice Personal physician leads a team of individuals at the practice level The team takes collective responsibility for patient care We are now going to look at some of the elements of the patient-centered medical home or PCMH. The first characteristic is the concept of a personal physician. Each patient has an ongoing relationship with a personal physician. The physician is trained to provide continuous and comprehensive care and often acts as the first contact for the patient in the health care universe. The patient-centered medical home embraces the concept of a physician-directed medical practice. The personal physician directs care for the patient by leading a team of individuals at the practice level, and while the team takes collective responsibility for patient care, the physician often coordinates the activities of the team.

Whole Person Orientation Personal physician is responsible for providing for all the patient’s health care needs Care is provided in all stages of life Care is provided in multiple settings Acute care Chronic care End-of-life care Preventive services are emphasized Another characteristic of the patient-centered medical home is the concept of whole person orientation. This suggests that the personal physician is responsible for providing for all of the patient’s health care needs. The physician may seek assistance through consultation from other clinicians, if appropriate, but aims to provide care for the patient in all stages of life. Care is provided even in the acute, chronic, and end-of-life settings. Preventive services are emphasized and provided by the personal physician.

Coordination of Care Care is coordinated and/or integrated across all elements of the health care system and the patient’s community Care is facilitated by technology Clinicians provide care that is culturally and linguistically appropriate The patient-centered medical home mandates coordination of care. Coordinated or integrated care is provided to the patient across all elements of the health care system and within the patient’s community. Care is facilitated by technology so that patients get appropriate care when and where they need it. Clinicians are trained to provide care that is culturally and linguistically appropriate. In this setting, the health care system includes subspecialty care, hospitals, home health agencies, or nursing homes. The patient’s community includes family, public, or private community-based services; and the concept of technology includes electronic health records, health information exchanges, information technology registries, and other means to provide appropriate care.

Quality and Safety - 1 Incorporated as essential component of care Patients are encouraged to achieve patient-centered outcomes Clinicians use evidence based medicine and clinical decision support tools to guide their decision making Uses information technology to support patient care Quality and safety are important characteristics of the model. Quality and safety measures are incorporated as an essential component of patient care. Patients are encouraged to achieve patient-centered outcomes and are assisted by a care planning process and a strong partnership between the physician, the patient, and the patient’s family. Clinicians use evidence-based medicine and clinical decision support tools to guide their decision making in order to ensure a standard of quality and safety that is acceptable. The patient-centered medical home emphasizes quality and safety of care. The model uses information technology to support patient care and makes use of tools such as performance measurement, patient education, and enhanced communication to improve quality and safety.

Quality and Safety - 2 Practices agree to undergo voluntary recognition process Physicians participate in continuous quality improvement and performance measurement Patients participate in decision-making Patients and families participate in quality improvement activities Further, practices go through a voluntary recognition process by an appropriate non-governmental entity, for example, the National Committee for Quality Assurance’s Physician Practice Connection’s and Patient-Centered Medical Home recognition program, to demonstrate that they have the capabilities to provide patient-centered services consistent with the PCMH model. Participation is an important aspect of maintaining quality and safety in the PCMH model. Physicians participate in continuous quality improvement and performance measurement. Patients participate in decision making and are able to provide feedback if their expectations are being met, or if they are not, and both patients and their families participate in quality improvement activities.

Enhanced Access to Care Improves current mode of care access and facilitates availability of clinical services This may include: Open-access scheduling Expanded hours New options for communication Secure messaging and email Use of personal health records The patient-centered medical home also enhances access to care. It specifies improvement in the current model of care access and facilitates the availability of clinical services for patients by using innovative methods of scheduling. This may be done by open access scheduling in the outpatient setting, by expanding hours for clinician/patient contact, and by offering new options for communication between the patient, their personal physician, and the practice staff. These options may be implemented using methods such as secure online messaging between clinicians and patients, and the use of personal health records.

Payment - 1 Payment appropriately recognizes the added value of a patient-centered medical home Reflects the value of patient-centered care management work Pays for face-to-face visits as well as services associated with coordination of care In the traditional model of medical care, payment for health care services typically reflects face-to-face services provided by the clinician to the patient. In patient-centered medical home, the payment model is enlarged to appropriately recognize the added value provided to patients who select the patient-centered medical home. It also reflects the value of physician and non-physician staff, and patient-centered care management work that falls outside of the face-to-face encounter. Payment for coordination of care includes care provided within a given practice, as well as care provided between consultants, ancillary providers, and community resources. These options include payments for face-to-face visits, and also for services associated with coordination of care.

Payment - 2 Additionally, the PCMH payment model Recognizes case mix differences in the practice patient population Allows for additional payments when quality improvements are achieved Covers enhanced patient communication access to clinicians Supports adoption and use of health information technology So, the payment model associated with the patient-centered medical home recognizes the value of physician work that is not necessarily delivered in a face-to-face environment with the patient. For example, if the physician remotely assesses patient clinical data, then there is a methodology of payment for these services. There is also a methodology for payment reimbursement for enhanced patient communication access to clinicians, including secure email, telephone consultations, and consultations between an interdisciplinary team that provides care. Additionally, the model also recognizes case mix differences in the practice’s patient population. A practice that has a larger number of more complex patients has payment options that are weighted to reflect the complexity of their population. The model also allows for additional payments when measurable and continuous quality improvements are achieved and surpassed. It also covers enhanced patient communication, access to clinicians, and supports the adoption and use of health information technology for quality improvement.

Evolution of Care Coordination Affordable Care Act introduced the concept of Accountable Care Organizations (ACOs) Provide flexible financial support in exchange for accepting accountability for overall quality and cost, aka “shared savings” (Pham, 2015) Payment models usually involve “bundled” payment to manage a patient with specific diagnoses or perform specific procedures, with additional payment for achieving specified quality measures The Affordable Care Act introduced another type of care coordination called Accountable Care Organizations, or ACOs. ACOs provide flexible financial support in exchange for accepting accountability for overall quality and cost, which is sometimes called shared savings. Payment models usually involve bundled payment to manage a patient with specific diagnoses or perform specific procedures, with additional payment for achieving specific quality measures. Health IT Workforce Curriculum Version 4.0

Evolution of and Trends in Health Care in the U.S. Summary – Lecture d Described characteristics of the Patient-Centered Medical Home (PCMH) including personal physician, team approach to care, whole person integrated approach, quality and safety measures, enhanced access, and payment Introduced new models of care coordination, in particular Accountable Care Organizations (ACOs) This concludes lecture d of The Evolution of and Trends in Health Care in the U.S. In summary, this lecture described features of the patient-centered medical home including having a relationship with a personal physician; a team approach to care; a whole person, integrated approach to care; care that includes quality and safety measures; enhanced access to care for patients; and payment that recognizes the added value of the patient-centered medical home. This lecture also introduced new models of care coordination, in particular, Accountable Care Organizations- ACOs.

Evolution of and Trends in Health Care in the U.S. Summary Described evidence-based medicine and its applications, including clinical practice guidelines Introduced health care quality improvement And, described models of care coordination, with emphasis on the patient-centered medical home This also concludes the unit: The Evolution of and Trends in Health Care in the U.S. In summary, this unit described evidence-based medicine and its applications, including clinical practice guidelines. It discussed the importance of health care quality improvement and introduced quality indicators and quality improvement methodology. Finally, it described coordinated care models, including the patient-centered medical home.

Evolution of and Trends in Health Care in the U. S Evolution of and Trends in Health Care in the U.S. References – Lecture d References American Academy of Pediatrics, Medical Home Initiatives for Children with Special Needs Project Advisory Committee (2002). The medical home. Pediatrics, 110, 184-186. Joint Principles of the Patient Centered Medical Home. (2007). Retrieved February 1, 2017, from Patient-centered Primary Care Collaborative - American Academy of Family Physicians (AAFP); American Academy of Pediatrics (AAP); American College of Physicians (ACP); American Osteopathic Association (AOA) website: https://pcpcc.org/about/medical-home. Pediatric Records and a "Medical Home". (1967). In Standards of Child Care (pp. 77-79). Evanston, IL: American Academy of Pediatrics. Patient-Centered Medical Home Recognition, NCQA, Retrieved February 1, 2017. http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh Pham, HH, Pilotte, J, et al. (2015). Medicare's vision for delivery-system reform - the role of ACOs. New England Journal of Medicine. 373: 987-990. No Audio

Introduction to Health Care and Public Health in the U. S Introduction to Health Care and Public Health in the U.S. Evolution of and Trends in Health Care in the U.S. Lecture d This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. No Audio. Health IT Workforce Curriculum Version 4.0