Facility Design with the Patients at the Center Patient-Centered Medical Home Model: Impact on Ambulatory Care Design November 17, 2015

The Changing Landscape of Healthcare ■ The “business” of healthcare ■ PCMH approach ■ Patient experience ■ Caregiver roles

The Business of Healthcare Triple Aim ■ Increase quality ■ Enhance experience ■ Decrease cost Population Health ■ Increase access ■ Increase satisfaction and engagement ■ Collaborative, comprehensive care team

The Business of Healthcare Reimbursement Changing ■ Cost reduction pressures ■ Pay for value Migration of Care ■ Accountable Care Organizations (ACOs) ■ Care delivery moving from acute to ambulatory clinics ■ Care delivered by clinicians “practicing at the top of their license”

Volumes Continuing to Shift Outpatient Source: “Report to the Congress: Medicare Payment Policy,” MedPAC, March 2014, available at: Marketing and Planning Leadership Council interviews and analysis. Outpatient services represent entire market regardless of site of service (includes hospital-based settings, ASCs, other freestanding providers and physician offices) Medicare Volume Growth Cumulative Percent Change All Payer Volume Growth Projections % (12.6%) Cardiac Services Vascular Services Orthopedics Neurosurgery Volume Performance

Major Opportunity to Shift Primary Care Volumes Primary Care Network Redistributing Non-emergent Care to Appropriate Lowest-Acuity Sites Source: CDC/NCHS, "National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey," ; “Primary Care Physician Shortages Could be Eliminated Through Use of Teams, Nonphysicians, and Electronic Communication,” Health Affairs 32:1. Jan Health Care Advisory Board interviews and analysis. Annual Visits to PCPs Annual ED Visits Visits Eligible for NP-Led Care 103M 47M 132M Non-urgent ED Visits Shifted to Other Care Sites 573M 18% of PCP visits could be handled by NPs at convenient care sites Non-urgent ED visits could be treated at urgent care, retail or primary care Visits At Risk of Shifting to Other Sites of Care

Patient Preferences for Online Care Growing Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis. Based on proportions of respondents interested in teleheatlh. Survey Finds Visits Preferred to Clinic Near Errands or Work Increasing Consumer Preference ing provider with symptoms Preference for Location of Services Clinic located near work Clinic located near errands Clinic located near the home Young, Wealthy, Busy—Strongest Potential Telehealth Targets 1 Of yrs olds 54% Of those making >$71K per year 49% Of those working >35 hours per week 53%

Outpatient Environments Facilities are Leaner 1 ■ Little or no private physician spaces ■ Construction $ concentrated on clinical spaces ■ Ability to see more patients & increase profits Source: The New Medical Office Building; Building Design & Construction; September 2013

Traditional Outpatient Clinic Flow Appointment Check-in Vitals and Rooming Presentation to Physician Additional Testing Consult After Additional Testing Treatment Consult Check-out

Traditional Outpatient Clinic ■ An experience we’ve all had ■ Door to doctor to door

Core Patient Centered Medical Home Principles 1.Quality and safety as top goals 2.Physician directed practice 3.Personal physician 4.Whole person orientation 5.Coordinated care 6.Enhanced access 7.Revised, appropriate payment

PCMH Model Clinic Flow Appointment Staff Collects All Provider History Care Planning Collaboration Testing Imaging Engagement/ Wellness Education Planned Follow-up with Patient Check-out Physician Nurse/NP Behavioral Cardiologist Specialist Nutritionist Social Worker Pharmacist Check-in Vitals and Rooming Testing Imaging Health

People — Patients Greater ■ Agency and engagement ■ Holistic and integrated care ■ Accountability ■ Transparency Less ■ Difficulty getting access ■ DIY coordination

Source: Health Care Advisory Board interviews and analysis. Day 1 Day 365 Care Decision Network Selection and Ongoing Experience Care Decision Clinical interactions represent repeated opportunities to reinforce patient preference through superior experience Annual network selection in fluid insurance market implies consistent reevaluation of network performance Patient Experience Patient Experience Vital for Securing Purchaser Choice Year Over Year

Consumers’ Top 10 Prioritizing Convenience and Affordability Average Utilities for Top Ten Preferred Primary Care Clinic Attributes n=3,873 If I need lab tests or x-rays, I can get them done at the clinic instead of going to another location The provider is in-network for my insurer The visit will be free The clinic is open 24 hours a day, 7 days a week I can get an appointment for later today The provider explains possible causes of my illness and helps me plan ways to stay healthy in the future Each time I visit the clinic, the same provider will treat me If I need a prescription, I can get it filled at the clinic instead of going to another location The clinic is located near my home I can walk in without an appointment, and I’m guaranteed to be seen within 30 minutes Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis. Primary Care Clinic Attributes

Caregiver Roles Work is more ■ Collaborative ■ Distributed ■ Connected ■ Measured

People — Clinicians ■ Care team manager as ‘conductor’ of care ■ Physician as clinical team leader ■ Greater responsibilities for nurse and MAs ■ Treat patient at the appropriate level ■ Practice at ‘top of license’

Expanded Services ■ Behavioral health specialists ■ Social workers ■ Pharmacist ■ Nutritionist ■ Outgoing call center ■ Administrative support

■ Patient need drives flow: preventative, acute, chronic ■ Broader range of activities and interactions ■ Engagement and education The PCMH Clinic — Across the Continuum

Process Changes and Implications 1.Increase in consultations 2.Clinical encounters: vary in function, type, and group size 3.Patient engagement is critical 4.Treating patients at the appropriate clinical level 5.Technology is integral and foundational