1. Transforming Primary Care: What Works and What’s Next
A chartbook created by the staff of
Improving Chronic Illness Care
At the MacColl Institute for Healthcare Innovation
Group Health Research Institute
Supported by The Robert Wood Johnson Foundation
Grant #

2. I. Primary care in crisis2

3. Changing demography and practice content Substantial proportion of ambulatory visits among adults are for chronic illness management1
Chronic problem— routine
Chronic problem— flare-up
All patients
30% 9%
Age 25-44
26%
Age 45-64
37%
10%
Age 65+
42%
11%
1 “National Ambulatory Medical Care Survey.” Advance Data, No., 387, Accessed December 13, 2009, from
Note: See slide notes for citations in this chartbook or the CD’s Articles & Websites section. 3

4. Greater care complexity
Studies2,3 estimate that it would take 7.4 hours to deliver all recommended preventive services and hours per working day to deliver all evidence-based care for chronic conditions to a primary care panel.
“These excessive demands contribute to long waiting times and inadequate quality of care for patients.”4
Concern about one’s ability to manage complex, chronically ill patients may contribute to driving career choice away from primary care.
2 Primary Care: Is There Enough Time for Prevention? Kimberly S. H. Yarnall, Kathryn I. Pollak, Truls Østbye, Katrina M. Krause, and J. Lloyd MichenerAm J Public Health April; 93(4): 635–641. Pubmed Identification (PMID): PMC
3 Is there time for management of patients with chronic diseases in primary care? Østbye, T., Yarnall K.S., Krause, K.M., Pollak, K.I., Gradison, M., Michener JL. Ann Fam Med May-June; 3(3): PMID:
4 Primary care—will it survive? Bodenheimer, T. N Engl J Med Aug. 31; 355(9): PMID: 4

5. Quality of current primary care
Patients with major chronic illnesses receive recommended care about half of the time.5
Half of patients leave the doctor’s office without understanding what their physician said.6,7
These deficits are now perceived by patients, physicians and policymakers.8
Public
Physicians
Policymakers
People with chronic conditions usually receive adequate medical care
48%
45%
22%
5 The quality of health care delivered to adults in the United States. McGlynn, E.A., Asch, S.M., Adams, J., et al. N Engl J Med June 26; 348: PMID:
6 Studies of doctor-patient interaction. Roter, D.L., Hall, J.A. Annu Rev Public Health. 1989;10: PMID:
7 Closing the loop: physician communication with diabetic patients who have low health literacy. Schillinger, D., Piette, J., Grumbach, K., et al. Arch Intern Med Jan. 13.; 163(1): PMID:
8 Physician, Public and Policy-Maker Perspectives on Chronic Disease Conditions. Anderson, G.F. Archives of Internal Medicine. Feb. 24, 2003: 163(4); PMID: 5

6. The physician workforce in decline
The proportion of Internal Medicine residents becoming generalists declined from 55% to 2% within a decade.9
Income, debt and work hours are all cited as factors.
9Factors associated with medical students' career choices regarding internal medicine. Hauer, K.E., Durning, S.J., Kernan W.N., Fagan, M.J., Mintz, M., O'Sullivan, P.S., Battistone, M., DeFer, T., Elnicki, M., Harrell, H., Reddy, S., Boscardin, C.K., Schwartz, M.D. JAMA Sept. 10; 300(10): PMID: 6

7. A need for major healthcare reform
Do primary care physicians (PCPs) in the U.S. and elsewhere see the need for major healthcare reform?10
Percent saying
AUS
CAN FR
GER
ITA
NET NZ
NOR
SWE UK US
Only minor changes are needed 23 33 41 18 38 60 42 56 37 47 17
Fundamental changes are needed 71 62 53 51 58 57 40 54 50 67
System needs to be completely rebuilt 6 4 31 1 2 7 3 15
10 A survey of primary care physicians in eleven countries, 2009: Perspectives on care, costs, and experiences. Schoen, C., Osborn, R., Doty, M.M., Squires, D., Peugh, J., Applebaum, S. Health Aff (Millwood) Nov.-Dec.; 28(6): w Epub, Nov. 2. PMID: 7

8. Primary care’s decline: Does it matter?
The vast majority of the population prefers a PCP, while 95% of Americans want one practice and/or clinic where doctors and nurses know you, provide and coordinate the care that you need.11
Countries with better primary care have better health outcomes.12
U.S. states with higher primary care/population ratios have reduced costs and better quality healthcare.13
11 Toward higher-performance health systems: adults' health care experiences in seven countries, Schoen, C., Osborn, R., Doty, M.M., Bishop, M., Peugh, J., Murukutla. N. Health Aff (Millwood) Nov-Dec; 26(6):w PMID:
12 Contribution of primary care to health systems and health. Starfield, B., Shi, L., Macinko, J. Milbank Q. 2005; 83: PMID:
13 Quantifying the health benefits of primary care physician supply in the United States. Macinko, J., Starfield, B., Shi, L. Int J Health Serv. 2007; 37(1): PMID: 8

9. And how will we pay for healthcare?
The U.S. is currently spending 17% of GDP, the most of any nation.14
If healthcare spending grows at the current rate, a staggering 119% of the real increase in income over the next eight decades will be consumed by healthcare spending, leaving nothing for other needs.
14 Increased spending on health care: Long-term implications for the nation. Chernew, M.E., Hirth, R.A., Cutler, D.M. Health Aff (Millwood) Sept.-Oct.; 28(5): PMID: 9

10. What can we do?
The future of primary care (and our healthcare system) depends upon its ability to improve the quality and efficiency of its care for the chronically ill.
It will also require a recommitment of primary care to meet the needs of patients for timely, patient-centered, continuous and coordinated care.
That will require a major transformation or redesign of practice, not just better reimbursement.
However, such transformations will be difficult to motivate or sustain without payment reform. 10

11. II. What works 11

12. What works – Previous disks in this series
Volume 1: “Tackling the Chronic Care Crisis” explained the Chronic Care Model (CCM) and summarized the evidence base that has developed in the last decade.
Visit our website at: is_CD-Rom&s=172 12

13. What works – Previous disks in this series
Leadership
Volume 2: “It Takes A Region” examined the developing evidence base for regional healthcare improvement and proposed a framework to guide community improvement efforts.
Visit our website at: Rom&s=238 13

14. What works: Other tools developed by ICIC
Visit our website, to learn more about the following tools:*
We have a practice toolkit, available to download from our website, that is a summary of our lessons learned and a repository of useful tools.
We also have a toolkit to provide busy clinical practices with a set of tested resources and tools to share with patients and families in the day-to-day management of chronic conditions.
You can access the tools on our website using the following links:
“Integrating Chronic Care and Business Strategies in the Safety Net: A toolkit for Primary Care Practices and Clinics” can be found at:
"Partnering in Self-Management Support: A Toolkit for Clinicians” can be found at: Management_Support&s=39 14
* See the slide notes page for specific URLs.

15. What qualities do practices with improved outcomes share?
Success factors
What qualities do practices with improved outcomes share?
Team care – Clinical tasks shared with non-physician staff
2. Information technology – Functions that support healthcare planning and proactive, population based care
3. Planned care – Patient needs identified prior to encounters and systematically addressed
4. Self-management support – Engaging patients as partners in care 15

16. Successful care depends on everyone on the team
For example: Depression Management
Medical assistant administers PHQ-9
MD diagnoses depression and initiates treatment
Population manager enters patient and data in registry
Care manager follows the patient over time provides self-management support
Consulting psychiatrist provides advice and care manager and MD 16

17. Create a successful team
Plan and improve care together.
Define roles and tasks and distribute them among team members.
Train people for their roles. 17

18. Incorporate improvement into daily work
Meet briefly and often to review performance and plan PDSA cycles.
Make improvement a part of the clinical team’s day-to-day thinking and work.
Communicate regularly with senior leaders to discuss successes and barriers. 18

19. Successful teams use a registry
For example: Most of the Medicare plans providing the best diabetes care use a registry.15
Characteristic
High-performing plans
Low-performing plans P
HbA1c >9.5
20%
49%
Use of a registry
78%
40%
.02
15 The relationship between organizational systems and clinical quality in diabetes care. Fleming, B., Silver, A., Ocepek-Welikson, K., Keller, D. Am J Manag Care Dec.; 10(12): PMID: 19

20. Why is registry functionality so critical?
Population management
Allows practices to monitor entire practice panel and reach out to those needing service.
Encounter planning and reminders
Easy access to data on guideline adherence and key indicators facilitates productive interactions.
Performance measurement 20

21. Successful teams support self-management
Organize and train team members to provide basic self-management support.
Identify and use effective self-management support resources in their area.
Make self-management support a part of every interaction. 21

22. Self-management support must include key community resources
Encourage patients to participate in effective community programs that provide important services (e.g. exercise, self-management support, smoking cessation, peer support, etc.).
Form partnerships with key community organizations to support or develop programs. 22

23. What works
Organizational and environmental factors associated with high-quality care
Leadership — Leader attitudes about and level of support for QI a strong predictor of success.
Financing — Providing financial incentives for transforming practice predicts involvement in QI and perhaps success.
Effective practice management systems — Must be in place for practices to transform their clinical systems. 23

24. What works
Organizational and environmental factors associated with high-quality care
Trusted performance measurement is a powerful motivator for practice involvement in QI.
Networking smaller practices can provide leadership, motivation and support for otherwise isolated practices to engage in QI. 24

25. What works: Formal learning structures
like breakthrough series collaboratives
Over the last decade we have worked directly or indirectly with over 1,500 practices in collaboratives
Teams that use PDSA cycles based on the CCM systematically over time:16
Usually see process improvement
May or may not see outcome improvement
Enjoy their work more
16Evidence on the Chronic Care Model in the new millennium. Coleman, K., Austin, B.T., Brach C, Wagner, E.H. Health Aff (Millwood) Jan.-Feb.; 28(1): PMID: 25

26. Limitations of breakthrough series collaboratives
Collaboratives have demonstrated positive change, but there are limits:
Small percentage of eligible practices participate — usually early adopters
Reach within a practice organization limited to the most motivated
Changes often made in ways that are not sustainable
Can encourage project-based (i.e. time-limited) thinking 26

27. III. What’s next: The promise and challenge of the Patient-Centered Medical Home (PCMH)27

28. The CCM and the PCMH: Complementary models
Primary care is regarded as a linchpin to current healthcare reform efforts.
The PCMH is being proposed as a way to rejuvenate primary care.
The current PCMH model is a combination of the CCM and the Pediatric Medical Home model. 28

29. Understanding the origin of the Patient-Centered Medical Home
The Pediatric Medical Home concept arose out of frustration with the fragmented care of children with special needs.
Medical Home model puts the relationship with the PCP and team at the center of a patient’s care, and makes explicit the expectations of the PCP to provide timely, continuous, patient-centered and coordinated care. 29

30. Understanding the origin of the Patient-Centered Medical Home
Both the PCMH and CCM rest on the clinical evidence of practice changes that lead to improvements in patient care and outcomes.
Both models advocate that every healthcare experience (e.g. visit, referral, admission, etc.) connects the patient back to their PCP.
Both emphasize and support the patient role in decision-making and care. 30

31. Key features of a Patient-Centered Medical Home17
Personal physician – First contact, continuous and comprehensive care
Team care – Collectively take responsibility for ongoing care
Whole person orientation – Take responsibility for all patient needs by delivering or arranging care
Coordinated care – Across all elements of the healthcare system
Quality and safety – By implementation of CCM, continuous QI and voluntary recognition process
Enhanced access – Via open scheduling, expanded hours and new options for communication
Payment – Recognizes value of the PCMH, pays for coordination and electronic communication with patients, and supports IT use
17Joint Principles of the Patient-Centered Medical Home — March The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, published the Joint Principles in The statement can be accessed at: 31

32. Is the Patient-Centered Medical Home based on evidence?
The CCM holds considerable evidence of salutary effects on quality of care.16
Improved continuity is associated with better healthcare, patient satisfaction and outcomes.18
Access and coordination are valued by patients, and interventions directed at improving transitional care have improved care and outcomes.19
16 Evidence on the Chronic Care Model in the new millennium. Coleman, K., Austin, B.T., Brach, C., Wagner, E.H. Health Aff (Millwood) Jan.-Feb.; 28(1): PMID:
18 Continuity of care: a multidisciplinary review. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. British Medical Journal. 2003; 327(7425): PMID:
19 Coordinating Care – a perilous journey through the health care system. Bodenheimer, T. N Engl J Med Mar. 6; 358(10): PMID: 32

33. What are the goals of the PCMH?
For long-term success and impact, PCMH practices must:
1. Improve outcomes for patients with major chronic illnesses.
2. Reduce costs through fewer emergency room visits and hospitalizations (especially re-admissions and admissions for ambulatory-sensitive conditions.
3. Improve both patient and provider experience. 33

34. Can these goals be achieved?
The Group Health PCMH Pilot20
PCMH implemented in one primary care clinic with 10,000 patients
Compared with two other clinics with similar baseline performance
One year, in comparison with control clinics, the PCMH clinic experienced:
Greater improvement in patient experience
Dramatic reductions in provider burnout and dissatisfaction
Small improvements in clinical quality across the board
Significant reductions in avoidable hospitalizations and emergency room and urgent-care visits
Improvements largely maintained in year two
20 Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Reid, R.J., Fishman, P.A., Yu, 0., Ross, T.R., Tufano, J.T., Soman, M.P., Larson, E.B. Am J Manag Care Sept. 1; 15(9):e71-87 PMID: 34

35. What we are learning about implementing the PCMH21
Practice transformation requires “epic … redesign,” not just incremental changes.
Even in practices with EMRs, achieving “meaningful use” often requires major educational and technologic intervention.
Change fatigue is a serious concern.
To make changes, practices need “adaptive reserve” — leadership, QI time and solid relationships to weather the storm.
Transformation is local; intervention ideas must be molded to fit local environments.
21 Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Nutting, P.A., et al. Ann Fam Med May-June; 7(3): PMID: 35

36. What we still need to learn about the elements of the PCMH model
Practical approaches for making self-management support a routine component of all transactions with patients.
How best to provide 24/7 access. Which coverage alternatives best meet patient needs and reduce ER and hospital use?
How best to coordinate care and link to community resources. Which alternatives best meet patient and provider needs and reduce ER and hospital use? 36

37. What we still need to learn about implementation
Is there a best QI method to support PCMH implementation?
Is there a best strategy for supporting practices involved in PCMH implementation?
What practice payment reforms best motivate engagement in transformation?
What practice payment reforms lead to the most successful and sustainable implementation of the PCMH?
How important is networking of smaller practices, and what network structures are most successful?
How do we best measure PCMH implementation and effectiveness? 37

38. Transformation is a Developmental Process21
It begins with a solid core structure.
Well-functioning clinical and QI teams
Effective financial management
Committed leadership
Functional IT
Develop or nurture the “adaptive reserve”.
Try to change both the practice AND the environment in which the practice operates (e.g. the medical neighborhood).
Have to address professional isolation and relationships between primary and hospital/specialty care
Try to address financial barriers and incentives with payors
21 Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Nutting, P.A., et al. Ann Fam Med May-June; 7(3): PMID: 38

39. The structural barriers to overcome becoming a medical home
Difficulty defining the practice’s “panel”
Lack of supportive information technology
Lack of financial incentives
Lack of hospital or specialist support of care coordination
Practice isolation from partners and QI infrastructure 39

40. A real opportunity
There is real possibility of healthcare reform that includes an emphasis on primary care renewal.
There is strong support for a model (the PCMH) that can improve healthcare and reduce costs.
There is growing evidence and experience base for transforming practice. 40

41. Thank you to The Robert Wood Johnson Foundation and to all of our partners in improving chronic care over the last decade. 41

42. Continue to find us at: 42