1. Humboldt Del-Norte Primary Care Renewal “ A Regional Collaboration to Improve Population Health, Individual Patient Experience, and Lower the Total Cost of Care” Alan Glaseroff MD, CMO Humboldt Independent Practice Association Humboldt ITUP Conference 12/1/09

2. Humboldt Del-Norte Determinants of Health and Their Contribution to Premature Death Schroeder, NEJM 357; 12 15% 5% 10% 40% 30% Social Environmental Medical Behavioral Genetic

3. Humboldt Del-Norte Patient Driven Care Patients are the most important factor in their own outcomes Patients receive care from someone they know and trust Patients are able to access information directly What is the role of the care team in this “Reformation”?

4. Humboldt Del-Norte The Care Model – “The Wheel Invented…”

5. Humboldt Del-Norte Core of Chronic Care

6. Humboldt Del-Norte “A Little Assembly Required…” “The person who invented the wheel was pretty smart, but the person who invented the other three was a genius!” Uwe Rheinhart, Princeton Health Economist

7. Humboldt Del-Norte Patients Hospital Services Family Clinician Practice Friends and Family Specialists Community The Medical Home: It Depends on Your Point-of-View… The “empowered patient” view…? Neighborhood Gym/ Recreation Place of Worship Workplace Internet

8. Humboldt Del-Norte Humboldt IPA –Started in 1996 –350 member IPA (210 physicians, 80 mid-levels, 60 mental health professionals) –7,500 HMO members, 4,000 PPO and self-funded –> 95% of all providers including safety net, average practice size 3 MDs –84 PCPs –BOD 50/50 PCPs and specialists –Unaffiliated with hospitals –Humboldt Diabetes Project: 83% of all pts with DM in registry; NCQA Recognition for DM 2004 –“Top Quality” in CA P4P program

9. Humboldt Del-Norte Practice Environment in Humboldt 25 primary care practices in various sizes, types and stages of transformation (all in the Humboldt IPA) –2/3 of patients receive care in either FQHCs or Rural Health Clinics –5 community health centers, Mobile Medical Clinic, United Indian Health –Many rural health clinics (small practices) –Many 1-3 clinician practices in private practices (one 17 MD Internal Medicine practice) –No large integrated multispecialty group –Managed care covering 5% of population How to rapidly improve chronic disease care in the community?

10. Humboldt Del-Norte Primary Care Renewal in Humboldt Trip to Group Health/Factoria and Care Oregon August 2008 to look at Medical Home/Care Support projects: “Build Your Own…” so we did Dr. Ed Wagner launch 11/08 14 teams 1/08 Added peer-educator team (POET) 10/09 Model for Improvement meets “5 Aims” –Clinician “permission” –Starts with team mtgs (process measure for collaborative) –MAs as medical professionals

11. Humboldt Del-Norte Team mtgs Model for Improvement: Pro-active Panel Management –Preventive and chronic care measures, “closing the loop” Access –ED visit comparative report and patient stories Patient-Driven/Integrating Behavioral Health –POET-led session – problem-solving from patient perspective +

12. Humboldt Del-Norte What We Have Learned So Far Exhortation/fear of exposure/incentives not enough: “Enlightened self-interest – imagine the perfect clinical day(dream)…” “Always start from the patient’s view” Clinicians need –Best practices –Coaching –Comparative data/feedback Workforce Development –MA II curriculum/certification –RN Care Support/Population Management –Peer-educators/coaches/navigators