THE COMMONWEALTH FUND Primary Care for 21 st Century High Performance Health Systems Potential to Improve and Opportunities to Learn HSRAANZ Conference, December 2011 Cathy Schoen, Senior Vice President The Commonwealth Fund

Primary Care for 21 st Century Health Care Systems Patient-Centered, High Performance Care Systems –Goals: Accessible, High Quality (Outcomes/Health) and Sustainable Costs –Primary care teams and “medical homes” potential Insights from 2011 International Survey of adults with serious acute or ongoing chronic disease –Often shared concerns in diverse systems –“Medical homes” make a difference Innovative models – U.S. examples –Teams –Information and new communication technology Opportunities to learn from country initiatives 2

Transforming Primary Care Patient-centered teams and Care Systems Patients receive enhanced access to primary care, well coordinated by a team Patients actively engaged (treatment decisions, care at home) Teams use decision- support tools, assess performance & receive payment support Linked to care continuum – care system; health focus 2020 Vision Accessible Patient Centered Coordinated Care

Patient-Centered Care and Care Systems: Primary Care Foundation Connected to Care System

Insights from Patient Experiences from 2011 International Survey in Eleven Countries Survey of “sicker” adults: –Serious acute or ongoing chronic care conditions –Recent hospital, surgery, serious illness, or fair/poor health Eleven Countries: –Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, U.K., and United States Often shared experiences in diverse care systems –Care coordination, safety, engaging patients –Medical homes (accessible, know patients, help coordinate care) make a positive difference 5

6 Cost-Related Access Problems in the Past Year Percent because of costs: AUSCANFRGERNETHNZNORSWESWIZUKUS Did not fill prescription or skipped doses Had a medical problem but did not visit doctor Skipped test, treatment, or follow-up Yes to at least one of the above Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

7 Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year Percent More than US$1,000 OOP Costs Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Serious Problems Paying or Unable to Pay Medical Bills

8 Access to Doctor or Nurse Last Time Sick or Needed Care Percent Same- or next-day appointment Waited six days or more Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

9 After-Hours Care and Emergency Room Use Percent Difficulty Getting After-Hours Care Without Going to the ER Used ER in Past Two Years Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

10 Experienced Coordination Gaps in Past Two Years Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. * Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

11 Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. * Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking. Gaps in Hospital or Surgery Discharge Planning in Past Two Years

12 Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. * Medical mistake, or wrong drug/wrong dose, incorrect lab test results, delay in hearing about abnormal lab test. Patient Reported Medical, Medication or Lab-Test Error in Past Two Years

Patient-Doctor Relationship and Communication Percent reported regular doctor always/often: AUSCANFRGERNETHNZNORSWESWIZUKUS Spends enough time with you Encourages you to ask questions and explains things in a way that is easy to understand Always/often to both Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Base: Has a regular doctor/place of care.

Patient Engagement in Care Management for Chronic Condition Percent reported professional in past year has: AUSCANFRGERNETHNZNORSWESWIZUKUS Discussed your main goals/ priorities Helped make treatment plan you could carry out in daily life Given clear instructions on symptoms and when to seek care Yes to all three Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Base: Has chronic condition.

15 Primary Care “Medical Homes” Accessible, Knows Medical History, Helps Coordinate care

Patients with a Regular Doctor vs. Medical Home 16 Percent Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

17 Percent reporting positive patient-doctor relationship and communication* Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Patient-Doctor Relationship and Communication, by Medical Home Base: Has a regular doctor/place of care. * Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way that is easy to understand.

Patient Engagement in Care Management for Chronic Condition, by Medical Home 18 Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Base: Has chronic condition. Percent reporting positive patient engagement in managing chronic condition* * Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.

19 Experienced Coordination Gaps in Past Two Years, by Medical Home Percent* Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. * Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.

20 Hospital or Surgery Discharge Planning Gap in Past Two Years, by Medical Home Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. * Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking. Percent*

21 Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home * Reported medical mistake, medication error, and/or lab test error or delay in past two years. Percent*

22 Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home Percent

Patient-Centered, Coordinated Primary Care Medical Homes as Part of Systems Approach Systems approach: Access, Quality, Efficiency Primary care medical or “health” homes –Timely access to care: multiple points of access –Patient engagement in care –Information systems: quality & coordination –Routine feedback of patient and clinical outcomes –Coordinated care, creative use of teams –Incentives and system support to improve/innovate Approach to redesigning primary care –Part of “system” of care the aims to organize care around patients and focus on outcomes 23

Community Care of North Carolina U.S. Multiple Models of Medical Homes and Teams

Examples of Cost and Quality Outcomes from Primary Care Medical Home Interventions Geisinger Health System (Pennsylvania) 18 percent reduction in all-cause hospital admissions; 36% lower readmissions 7 percent total medical cost savings Mass General High-Cost Medicare Chronic Care Demo (Massachusetts) 20 percent lower hospital admissions; 25% lower ED uses Mortality decline: 16 percent compared to 20% in control group 7% net savings annual Guided Care - Geriatric Patients (Baltimore, Maryland) 24 percent reduction in total hospital inpatient days; 15% fewer ER visits 37 percent decrease in skilled nursing facility days Annual net Medicare savings of $1,364 per patient Group Health Cooperative of Puget Sound (Seattle, Washington) 29 percent reduction in ER visits; 11% reduction ambulatory sensitive admissions Health Partners (Minnesota) 29% decrease ED visits; 24% decrease hospital admissions Intermountain Healthcare (Utah) Lower mortality; 10% relative reduction in hospitalization Highest $ savings for high-risk patients

Pennsylvania: Geisinger Medical “Navigator” Home Sites and Hospital Admissions/Readmissions Source: Geisinger Health System, *Results reported in: R. Gilfillan et al, “Value and the Medical Home: Effects of Transformed Primary Care,” The American Journal of Managed Care, 16(8) 2010: Hospital admissions per 1,000 Medicare patients 18% reduction in hospital admissions 36% reduction in hospital readmissions 7% total medical cost savings Readmission Rates for All Medical Home Sites As of Q4-2008*:

THE COMMONWEALTH FUND 27 Health IT Framework Evaluation Framework Medical Home Hospital s Public Health Programs & Services Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers MCAID Care Coordinators Public Health Specialist Specialty Care & Disease Management Programs  A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services  Multi Insurer Payment Reform that supports a foundation of medical homes and community health teams  A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry  An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact Mental Health & Substance Abuse Programs Medical Home Social, Economic, & Community Services Healthier Living Workshops Vermont: Shared Resources Community Teams

THE COMMONWEALTH FUND 28 International Innovations in Access “After-Hours” Early Morning, Nights and Weekends Denmark –County wide physician cooperatives with phone and visit center –Computer connections to medical records –Reduce physician workload Netherlands –2000/2003: Cooperatives evening to 8 AM and weekends; Nurse led with physician available –House calls for emergencies –Reduce physician workload and use of emergency rooms United Kingdom –Some cooperatives developing; walk-in centers –24 Hour Help Line: NHS Direct Source: Grol et al., “After-Hours Care in the U.K., Denmark, and the Netherlands: New Models,” Health Affairs, Nov./Dec. 2006; Schoen et al., “On the Front Lines of Care,” Health Affairs Nov. 2, 2006.

THE COMMONWEALTH FUND 29 24/7 Access: Dutch GP After-Hours Cooperatives Since the 2000s, 127 GP cooperatives; cover more than 90% of the population Access to after-hour primary care through single telephone number Community physicians rotate; nurse staffed – phone and visit Home visits with medically trained car drivers in fully equipped cars (e.g. O2, infusion drip, automatic defibrillation equipment) Electronic health records; communication to regular GP Source: J. Burgers, UMC St Radboud, Providing After-hours Primary Care in the Netherlands presentation at The Commonwealth Fund Harkness Alumni Policy Forum, May 20-22, 2011.

THE COMMONWEALTH FUND 30 Interdisciplinary teams; home and community care; transition care Care and assist with navigating complex health care systems Patient-centered: targets and customizes interventions Strong health information technology and EHR; Support team Positive results Improved primary care access; high quality and patient ratings Reduce hospital admissions, readmissions, ER use (17 to 27%) Links primary, specialist and long term care Patient and family preferences Visiting Nurse Service New York Health Plans Patient-Centered Care Teams for High-Cost Chronically Ill Medicare and Medicaid – Special Needs and Long Term Care Summary of presentation by Carol Raphael, Pres and CEO, NY Visiting Nurse Assn., 6/2011

THE COMMONWEALTH FUND 31 ED visits reduced 67% Hospital admissions reduced 84% Lost school days reduced 41% Missed work days (Parents/caregivers) reduced 55% Recipient of U.S. Environmental Protection Agency’s 2010 National Environmental Leadership Award in Asthma Management Home visits Medication education Asthma management tools for patients Understanding triggers and reducing triggers in the home Connecting families to community resources Source:

THE COMMONWEALTH FUND 32 Alaska Dental Health Aide Program Improves Access to Oral Health Care Began in 2003; first of its kind in the United States High unmet need, particularly in rural communities –Dentist shortages –High rates of oral diseases Dental therapists provide education, preventive services, and basic treatment in regional hub clinics and remote village clinics Focuses on reaching children, pregnant women, and other high-risk residents Evaluation: providing safe, competent, appropriate care Dental Health Aide Therapist Program, Class of 2010 Student in clinic Source: Alaska Dental Health Aide Therapist Initiative, Alaska Native Tribal Health Consortium.

THE COMMONWEALTH FUND 33 Creative Use of Information and Communication Technology

Boston Mass. General Hospital: Care Redesign T. Ferris, G. Meyer, P. Slavin presentation to Commonwealth Fund Longitudinal CareEpisodic Care Primary CareSpecialty CareHospital Care Access to care Patient portal/physician portal Hospital Access Center Extended office hours Reduced admits/1000 Non face-to-face visits Design of care Defined process standards in priority conditions (multidisciplinary teams) High risk care management Shared decision makingRe-admissions 100% preventive servicesAppropriateness Hand-off standards Continuity visit EHR with decision support and order entry Incentive programs Measurement Variance reporting/performance dashboards PMPM, HCI, ACSH, Pharmacy Clinical and Patient Reported Outcomes LOS, CMAD, HACs, Re-Admits

Parkland, Texas: An EMR model to predict 30-day readmission for heart failure using SES risk and clinical risk. Model includes: systolic and diastolic blood pressure, pulse, temperature, pH, BNP, PT/ INR, glucose, CK-MB, troponin, wbc, pCO2, BUN, sodium, creatinine, CK, bilirubin, albumin, age, history of depression, single, male, no. of home address changes, medicare, high risk census tract, cocaine use, missed clinic visit, used pharmacy, prior inpatient admissions, ED presentation time. C-statistic: Derivation: 0.73; Validation 0.69 Source: Ruben Amarasingham, MD, Parkland Health and Hospital System, Presentation to Commonwealth Fund on May 12, 2010, “Harnessing Electronic Medical Record Data to Reduce Readmissions.” Hospital: Use of IT to Predict Risk and Marshal Resources, Including Transition Care/Discharge

Telehealth & Electronic Communication Veteran’s Health Administration– Scaling up Telehealth Services North Dakota Telepharmacy Project – Reaching over 40,000 rural residents E-consults and referrals ―San Francisco General Hospital ―The Mayo Clinic ―Group Health

THE COMMONWEALTH FUND 37 Tele-Health and Electronic Communication: Enhanced Access and Care Teams Veteran’s Administration: serving 31,000 frail at home; aim to serve 92,000 by 2012 –High patient ratings; Link to care teams – home visits –40 percent reduction in “bed-days” by 2010 compared to start U.Tennessee Memphis: Remote specialist consultations with patients, local clinicians. Center serves 3 state region –Reduce heart failure admission + readmissions by 80% –“real time” diabetic retinopathy (digital) report results Primary care to Specialist e-consultations and referral –Mayo, SF General, Group Health Puget Sound Kaiser : Web access, e-visits/consultation - outreach and booking Henry Ford Detroit: Kiosks in churches, communities

THE COMMONWEALTH FUND 38 Teams and Care System Redesign Information Systems Payment Reform: Value Keys to Rapid Progress

THE COMMONWEALTH FUND 39 Primary Care Redesign Primary Care Teams, including Long Term Care –Expanded set of skills; new work roles –Nurse and medical assistants new roles and skills –Education and training –Everyone “working to top of skill set”; learning Shared resources include teams and information systems –Primary care and specialist linked through information systems: opportunities to learn, coach –Home care and long-term care nursing teams work with multiple practices Scope of practice, delegation to enable teamwork Prevention and population health: community health outreach

Primary Care, Health Care System and Population Health Whole system view –Health and value gains if we use resources more creatively and productively –Primary care, teams, information, shared services, population health – beyond “facilities” Focus on key areas –Transforming primary care, teams and care systems –Creative use of electronic health information systems and technology –Shared resources –Aligning Payment and Regulations with Value

THE COMMONWEALTH FUND 41 Better Population Health Better Care Experiences Slow or Reduce per Person Costs Primary Care Innovation: Rich Opportunities to Learn from International Initiatives Focused on Achieving Core Health Care System Goals Institute for Healthcare Improvement (IHI) Triple Aim

THE COMMONWEALTH FUND 42 For More Information Visit the Fund’s website at For survey results: C. Schoen, R. Osborn et al. “New 2011 Survey of Patients with Complex Needs Finds that Care Is Often Poorly Coordinated,” Health Affairs, Nov. 9, 2011 Web first

Survey Profile of Sicker Adults Percent AUSCANFRGERNETHNZNORSWESWIZUKUS Age 50 or older Has 2+ chronic conditions (out of 8) Health care use in past 2 years: Hospitalized Surgery Saw 4+ doctors Taking 4+ prescription medications regularly Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.