1. RICHARD J. BARON, MD, FACP CEO, GREENHOUSE INTERNISTS, PC DIABETES MANAGEMENT: BUILDING A COORDINATED CARE MODEL JEFFERSON SCHOOL OF POPULATION HEALTH OCTOBER 21, 2009 Improvement in Diabetes Care through the Patient Centered Medical Home

2. What is the Patient Centered Medical Home? Joint Principles AAP, AAFP, ACP, AOA NCQA PPC-PCMH Consumer Joint Principles Robert Graham Center: “A political construct”

3. Patient Centered Medical Home: ACP, AAP, AAFM, AOA Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Quality and safety Enhanced access Payment

4. NCQA PPC PCMH tool criteria Access and communication Patient tracking and registry Care management Patient self-management support Electronic prescribing Test tracking Referral tracking Performance reporting and improvement Advanced electronic communication

5. Consumer “Principles for Patient- and Family- Centered Care” Interdisciplinary team, patient at center Coordinates care across settings and time Patient has ready access to care PCMH “knows” its patients Patients and clinicians are partners in making decisions Open communication supported Patients and caregivers supported in managing the patient’s health Environment of trust and respect Safe, timely, effective, efficient, equitable, patient centered and family focused

6. PCMH Pilot in SEPA Began with ACP, AAFP working with IBC and Aetna Joined with a “Chronic Care Initiative” running out of PA GOHCR Brought in other payers, including  All 3 Medicaid MCOs  Cigna Does NOT include Medicare, United

7. Has engaged 32 practices Diversity of location, structure – Urban/suburban/rural – Solo up to academic group practice (including Jefferson Family Medicine) – Nurse managed health centers, FQHCs All participated in a “learning collaborative” focused on diabetes care management (adults) – Ed Wagner gave keynote, MacColl has provided support for 3 “Learning Sessions” – IPIP has provided ongoing coaching support for practice transformation

8. The challenge- and opportunity- of multi-payer Anti-trust issues for payers “New business development” issues for practices Uncertainty about what is being purchased, what is being sold PA one of the few multi-payer models with meaningful amounts of funding

9. Funding model State “names the number” Uses NCQA PPC-PCMH to “grade” practices Total payment based on NCQA level and #FTE docs Payers share pro rata in cost based on revenue share within a practice Payment is NOT tied to specific patients or services Practices free to innovate with resources to achieve goals

10. New Services Being Offered by PCMH Practices Self Management/Patient Education/Patient Outreach – Protocols for medical assistants to assess readiness to change. – Health coaching (2) – Nutritional counseling with dietician – Patient report cards (2) – Consistent integration/offering of written educational support materials to patients in the regular process of care – Walking program – Diabetic group classes (3) – Educator on staff (2) – Better patient self-management – Individual goal-setting program – Health action plans/patient activation – Regular telephone follow up with patients (2) – Outreach calls to patients – Regular newsletter Continued on next page

11. New Services Being Offered by PCMH Providers Case Management – Case management (5) – Better case management (1) – Care coordination (2) – Risk stratification of patients (3) Planned Visits – Pre-visit planning – Pre-visit standing orders for MAs – Planned visits (4) – Group visits Data Management – EMR (3) – Enhanced data tracking (4) – Monthly reporting system across providers (3)

12. Percent of SE PA Revenue Investment by Category (Percentages per practice totaled 100%)

13. Other responses: 1.Medical Home Assistant 2.Plan to hire nurse-not done yet 3.Part-time IT consultant to help with NCQA documentation 4.Added Endocrinologist and Cardiologist (cost neutral) 5.Planning to add Nutritionist 1 half-day per week 6.Part-time quality care coordinator

14. What we did at Greenhouse Hired a Health Educator:“50% wholesale, 50% retail” Retail – Meets 1:1 with patients (but we have 1200 diabetics!) – Does group classes, walking group (but we have 1200 diabetics!) – Follow up on “Diabetes results letters” Wholesale: engaging MAs in care planning – Standardized, EHR supported goal setting – Based on behavior change theory – Embedded in “rooming protocol” – Oversees “lost to follow up program”

15. Fewer people with A1C > 9 at Greenhouse

16. Fewer people with A1C > 9 in SEPA

17. More people with A1C < 7 in SEPA

18. Better BP control at Greenhouse

19. Better BP control in SEPA

20. Greenhouse improved self-management goal setting

21. Self-management goals in SEPA

22. Key issues to address Staff (re-)training, Work flow re-design Technology Provider (re-)training

23. Staff re-training Medical Assistants  Many come from “Welfare to work” programs  Have been trained to do VS, phlebotomy  We want them to be “chronic care managers” Front desk  Can do a lot more with EHR infrastructure  Pro-active calling  Insurance company administrative tasks

24. Work flow re-design As technology and staff change, so must work flow Some examples  Rx refills  DM “services due”  MA care plans, follow up

25. Technology EHRs need to be used “intentionally”  Examples of DM eye exams, foot exams Standardization  Do we all record key stuff the same way? Customization of HIT  First, try really hard to use what you have  Customization comes later

26. Doctors Increase focus on delegation  A dirty word for primary care docs  Need to be able to trust staff, process, technology Paradigm shift in “excellent care”  Not just knowing, but doing  All Boards supporting this  Numerator-denominator data forces shift Need to recognize time needs (e.g., “panel management”)

27. Resource issues Key piece of PCMH: new funding Many PCPs function in a larger enterprise  Decisions about staffing, workload, etc made outside the practice (and NOT by payers) As we have more clinical data, can use it aggressively to re-design payment/support  NOT “P4P”- needs to be HOW WE BUY