1. Whats Needed In Primary Care? J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community Research Bridging the Chasm Health Level Seven April 20, 2009 Washington, DC

2. Twenty years of experience trying to improve outcomes and lower costs for diverse communities in North Carolina

3. Community Care Partners 42,000 Medicaid patients, Durham (NPCCN), Vance, Granville, Warren, Person, and Franklin Counties in 34 primary care practices Primarily women and children, largely African-American, growing Latino population Teams of community health workers, DSS social workers, nurses work with patients at home Offer patient education, patient support, system navigation, and self- management skill training Electronically linked between practices, hospitals, DSS, Health Depts., and the teams Clinical Outcomes (State): 34% lower hospital admission rates 34% lower hospital admission rates 8% lower ED rate 8% lower ED rate Financial Outcomes (State): 24% lower average episode cost for children ($687 v $853) 24% lower average episode cost for children ($687 v $853) $3.5 million/yr for asthma management $3.5 million/yr for asthma management $2.1 million/yr for diabetes management $2.1 million/yr for diabetes management $60 million in SFY03 $60 million in SFY03 $124 million in SFY04 $124 million in SFY04 Total:

4. Walltown and Lyon Park Clinics Duke-Durham Neighborhood Partnership: Duke-Durham Neighborhood Partnership: Neighborhoods ask for access to care Neighborhoods ask for access to care Population: African-American, new Latino population, low-income, transient, uninsured Population: African-American, new Latino population, low-income, transient, uninsured Health characteristics: high ED use; inconsistent primary care, high risk health behaviors; substance abuse; depression/anxiety Health characteristics: high ED use; inconsistent primary care, high risk health behaviors; substance abuse; depression/anxiety 70% of visits are return visits (continuity) 70% of visits are return visits (continuity) 37% of patients surveyed would have gone to ED 37% of patients surveyed would have gone to ED High patient satisfaction – 4.7/5.0 High patient satisfaction – 4.7/5.0

5. Since 2000, serving 350 patients, average age 70 who have multiple chronic conditions Since 2000, serving 350 patients, average age 70 who have multiple chronic conditions 44% have mental illness 44% have mental illness All are home bound All are home bound 84% are African-American; many with low to no family support 84% are African-American; many with low to no family support Low literacy; illiterate Low literacy; illiterate Just for Us Annual Income $7,000 _ 25% Rent $5,250.00 / year Community Partners: City of Durham, Housing Authority Lincoln Community Health Center Durham Council on Seniors Area Mental Health Agency Durham County Health Department Durham County Department of Social Services Practice Partners: Duke CFM, SON, DUH, DRH, Center for Aging, Department of Psychiatry All patients with hypertension 79% 140/90 Diabetics with hypertension 84% 140/90 Outcomes Ambulance costs 49% ER costs 41% Inpatient costs 68% Prescription costs 25% Home health costs 52%

6. Community Redesign

7. Durham Health Innovations (DHI): City of Medicine/Community of Health Key points: Grants are for planning Grants are for planning Relationships and teamwork Relationships and teamwork Improve the health of our community Improve the health of our community Work with the DCCR Team and additional resources Work with the DCCR Team and additional resources This is a collaborative process – we will work together, learn together, and succeed together This is a collaborative process – we will work together, learn together, and succeed together

8. Proposals… 1.Adolescent Health 2.Asthma / COPD 3.Cancer 4.Cardiovascular Disease/CKD 5.Diabetes 6.HIV/AIDS, STDs, Hepatitis 7.Maternal Health 8.Obesity 9.Obesity & Wellness 10.Pain Management 11.Substance Abuse 12.Seniors Health

9. Medical Home Version 1 Focus: Improved outcomes for patients seen in office Care Location: Offices and hospitals IT: Minimal Provider: Physicians and Office team IT Office Anywhere Office Team Community Team Patients Physicians Hospital Example: Duke Family Medicine, Duke Primary Care, General Peds, Duke Outpatient Clinic

10. Medical Home Version 2 – Our Current State: What do We Have and What do We Still Need to Do? IT Office Anywhere Office Team Community Team Patients Physicians Hospital Communication Tools Telephone Email Text messages Kiosks Patient Portal Care Management Tools Risk assessment Data surveillance Care plans CMA/CHW Group visits Community Partners/Sites Neighborhood care Patient surveillance Point of care testing Neighborhood nurses Medication access Focus: Improved outcomes for patients seen across the spectrum of care Care Location: Offices and hospitals IT: Somewhat integrated Provider: Physicians, Office team, and Community team

11. Medical Home Version 3 – Connected Care IT Office Anywhere Office Team Community Team Patients Physicians Hospital Focus: Improved outcomes for all Care Location: Anywhere IT: Highly integrated Provider: Network

12. IT for Primary Care Whats Needed? 1.Shared patient data repository across community partners Prototype solution – COACH/NPCCN

13. Network Partners 2 Care Management Teams 2 Care Management Teams 34 Primary Care Clinics (FM, IM, Peds, Ob-Gyn, FQHC) 34 Primary Care Clinics (FM, IM, Peds, Ob-Gyn, FQHC) 3 Urgent Care Facilities 3 Urgent Care Facilities 5 Hospitals and Emergency Depts. 5 Hospitals and Emergency Depts. 8 Government Agencies (HD, DSS) 8 Government Agencies (HD, DSS)

14. HL7 DSS – Architectural Overview Decision Support Service Knowledge Modules Institution A Client Decision Support Apps Patient Data Sources Queries for required pt data Queries for required pt data Institution B Client Decision Support Apps Patient Data Sources Queries for required pt data Queries for required pt data Conclusions about patient Patient data, knowledge modules to use Patient data, knowledge modules to use ©2009 Kensaku Kawamoto Trigger HL7 DSS Standard Trigger

15. COACH HIE Context Enables Population Health Management model of care Enables Population Health Management model of care Supports care management activities (documentation, communication, referrals, care plans, etc.) Supports care management activities (documentation, communication, referrals, care plans, etc.) Receives and displays external billing/claims/clinical data from 5 hospitals, 8 clinics and NC State Medicaid Receives and displays external billing/claims/clinical data from 5 hospitals, 8 clinics and NC State Medicaid 6 Counties => 40,000 Medicaid Beneficiaries 6 Counties => 40,000 Medicaid Beneficiaries Centralized data repository Centralized data repository

16. 2.Systems to support population health management Prototype solution – COACH population health management system for NPCCN

17. CDS Repository HL7 Decision Support Service

18. COACH Sample Screen

19. Sample Provider Notice ©2009 David F. Lobach

20. 3.Tools to support efficient point-of-care decision making regarding health maintenance Prototype solution – eBrowser disease management dashboard

21. Duke eBrowser – Disease Management Module © 2007 David F. Lobach

22. 4.Ability to identify clinic and provider level performance on care quality metrics Prototype solution – DHTS care quality reports powered by CDR, DSR, and SEBASTIAN

23. Duke Health Disease Management System – Reporting for Diabetes © 2009 David F. Lobach

24. Outstanding Challenges Data standards (e.g., HL7 version 3 standards) are too complex and costly to routinely implement Data standards (e.g., HL7 version 3 standards) are too complex and costly to routinely implement Lack of incentives to share data Lack of incentives to share data Training on data collection and data entry Training on data collection and data entry