4. Build the proper structure Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of: Improve the patient experience (satisfaction) Improve the health of the population Control or reduce cost Then measure the outcomes

5. Identification and management of depression Management of care transitions Care coordination Team-based care Identification and management of socially frail/ isolated individuals Pharmacologic management including optimizing medication and dealing with adherence issues Enhancement of the therapeutic environment

7. Why its high leverage Very high prevalence Under diagnosed Major gaps in care Depressed individuals have more somatic complaints Chronic illness can produce depression Depression as a comorbidity roughly doubles the cost of the chronic illness

8. Using Technology Identify high risk patients (multiple chronic illnesses, multiple medications, unemployed, on disability…) Screening built into visits at regular intervals (e.g. PHQ2) Recall and tracking systems Medication adherence tracking Other resources Community resources On site integrated behavioral health (e.g. counselors, CNS) Liaison Psychiatrists and Psychologists

9. Why its high leverage High risk situation for both quality and cost outcomes Patients and families experience considerable anxiety and frustration at care transitions Improving care transitions reduces the incidence of hospitalizations and rehospitalizations

10. Using Technology On demand medical records access Hospital portal ED and hospitalist access to PCP medical record Automated HIE All ED notes, H & Ps, consults, op reports, labs, and imaging reports flow to EMR

11. Why its high leverage Community care of North Carolina, Geisinger Health System, Kaiser, Group Health of Puget Sound, and Voice of Detroit Initiative have all reported positive outcomes using imbedded care coordinators Care coordinators need to be part of the care team with a well defined specific role Remote third part care coordination and case management has been shown to not work as well

12. Using Technology Patient registries embedded in the EHR able to identify specific populations With particular diagnoses With gaps in care Who are overdue for services Who are not at goal With high illness burden With limited social supports Measure overall practice or physician performance Benchmarking

15. Why its high leverage MDs cannot provide all the care in the patient centered medical home model Consistent with the Chronic Care Model Improved quality and cost outcomes with team based care (Kaiser, Geisinger, Virginia Mason, CareOregon…)

16. Key processes Redefine roles and responsibilities including integrating BH, SW… The work is done by more people but needs to be coordinated Internal communication gets more complex Reframe patient expectations (this can be part of the PCMH) discussion Technology support Internal messaging IMs, Texting… Patient Portals Shared care plans (ideally web based that can be accessed by the entire care team) As well as what has become the floor but needs some refinishing CDSS, registries, and tracking systems

17. Definition: combination of social isolation and low self esteem Why its a high leverage process Four times the cost of matched populations Amenable to low cost interventions (brief intervention with a counselor significantly improves outcomes) Support groups, case management, plug in to local resources, pets… Risk equivalent to smoking a pack of cigarettes per day

18. Low self esteem- Question 6 on the PHQ9 are you feeling bad about yourself or that you are a failure or that you let yourself or your family down. Lubben Social Network Scale – 6 Family How many relatives do you here from at least once a month? How many relatives do you feel at ease with that you can talk about private matters? How many relatives do you feel close to such that you could call on them for help? Friendships How many of your do you see or hear from at least once a month? How many friends do you feel at ease with that you can talk about private matters? How many friends do you feel close to such that you could call on them for help?

20. Why its high leverage High prevalence of polypharmacy in patients with chronic illness Increased adverse drug events, drug-drug interactions Issues of non-adherence, affordability, and patient confusion Studies have shown decreased benefit when patients are taking more than four medication Significant morbidity, mortality and cost associated with medication mismanagement

21. Key functions Identify patients at risk due to polypharmacy and non- adherence Manage out of pocket costs Address various contributors to non-adherence Medication reconciliation Technology infrastructure EHR drug-drug and drug-condition programs Formulary management programs Filled prescription information Portal HIE Brainstorming ideas: Flash drives, medication reminder apps, blister packing

22. Why its a high leverage process. Patients highly value the relationship with their provider Continuity and the duration of the relationship correlate with positive outcomes Patients want a care team who take the time to listen to them and to know them as individuals The relationship often helps with patient activation Key functions Continuity Tracking patient preferences Access (visits, phone, e-mail…) Outreach Responsiveness Caring relationship

23. Technologic support Secure messaging Patient portal Web-sites Recall systems Patient interaction with EHR Use the EHR to track specific patient details

25. Superior clinical outcomes require investment in sustainable structures and processes Medical homes can help achieve the goals of improving the patient experience, reducing costs, and improving population health Focusing on highly leveraged processes and using technology are essential Using technology thoughtfully is equally important