View
217
Download
0
Embed Size (px)
Citation preview
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
1/48A
S p o n S o r e d b y :
The Commowealth Fud
Dartmouth Ititute for Health Policyad Cliical Practice
Patiet-Cetered PrimaryCare Collaborative
This report was written and produced by Health2 Resources with funding provided by the Milbank Memorial Fund
Better toBestValue-Drivi Elemet of the Patiet Cetered Medical Homead Accoutable Care OraizatioM A R C H 2 0 1 1 W A s H I n g T O n , D . C .
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
2/48
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
3/48
Contents
Acknowledgments 2
Meeting Attendees 4
Planning Committee 6
Letter from Donald M. Berwick, MD, Administrator,
Centers for Medicare & Medicaid Services 7
Preface 8
Introduction10
Enhanced Access to Medical Homes and Implications for ACOs 13
Discussion and Action Items 17
Better Care Coordination 20Discussion and Action Items 26
Better Health IT 28
Discussion and Action Items 33
Payment Reform for Primary Care Services 35
Discussion and Action Items 39
Closing Discussion, Group Consensus and Action Items 41
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
4/482
A s the patient centered medical home expandsits reach in dozens o demonstration and pilotprograms nationwide, much attention has been
paid to its proven worth in well-known models,measured in improved outcomes and lowered
costs. But a number o questions remain as to the
medical homes value as it is applied more broadly.
Will a ocus on the value-driving elements o the
medical homecare coordination, access, new
payment models that reward positive outcomes,
and the meaningul use o health ITenable its
more rapid expansion and greater return on
investment? And what will be the role o the medi-
cal home as accountable care organizations enter
the marketplace, spurred by rewards promised in
the Patient Protection and Aordable Care Act?How can health care leaders plan now to frmly
establish the medical home within the greater
medical neighborhood o the ACO?
These questions spurred a meeting o the minds
o the leadership o health plans, business member-
ship organizations, consumer groups, academia,
ederal health entities and policymakers as they
met September 8, 2010 or a high-level, invitation-
only discussion about transorming health care.
Hosted by the Patient-Centered Primary Care
Collaborative (PCPCC) and sponsored by TheCommonwealth Fund and the Dartmouth Institute
or Health Policy and Clinical Practice, the one-day
Consensus Meeting ostered rank dialogue and
robust discussion. By the end o the day, this group
o accomplished and nationally recognized busi-
ness, health care industry and thought leaders sat
shoulder-to-shoulder in a powerul demonstration o
solidarity to see the medical home and ACOs work
to support the Triple Aim: Better care or individuals;
better health or the community; and reduce,
or at least control, the per capita cost o care.
This document is a result o that meeting, and is
intended to activate participants and the broader
health care transormation audience to pursue
the recommendations and action items brought
orward to eect needed change. We would like
to thank Katherine H. Capps and her colleagues
at Health2 Resources who led the planning com-
mittee, managed and produced the meeting,
invited speakers and participants and produced
this document.
For their contributions at the Consensus Meeting,we would frst like to thank Don Berwick, MD, head
o the Centers or Medicare & Medicaid Services,
or providing inspiration and a ramework to reach
consensus. We are also grateul to our moderator,
Susan Denzter, or her gracious and inormed
leadership, and to Diane R. Rittenhouse, MD, M.P. H.,
or writing the oreword. Much gratitude is also
extended to the subject matter experts who con-
tributed the topic research papers that served as
the background reading in preparation or the
meeting, and to the presenters who crystallized key
topic points and kicked o discussion around eachtopic. This was an amazing collaborative eort,
and we are grateul to those who oered their
time and expertise; the names o the presenters
and contributors are listed at the right.
Thanks also are extended to our report sponsor,
Milbank Memorial Fund, and or the contributions
that made this report possible.
Acknowledgments
Paul Grundy, MD, M.P. H.,PCPCC President, and IBMsGlobal Director o HealthcareTransormation
Elliott S. Fisher, MD, M.P. H., Director,Center or Population Health,Dartmouth Institute or Health Policyand Clinical Practice
Karen Davis, Ph.D., President,The Commonwealth Fund
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
5/483
AccessPresenter:
Karen Davis,Ph.D., president,The Commonwealth Fund
Briefing document authors:
Melinda Abrams, MS, vice president,The Commonwealth Fund
Georgette Lawlor, program associate orpatient-centered coordinated care,The Commonwealth Fund
Steve Schoenbaum,MD, M.P. H., executive vicepresident or programs, The Commonwealth Fund
Karen Davis,Ph.D.,president,The Commonwealth Fund
Care CoordinationPresenters:
Elliott S. Fisher, MD, M.P. H., Director, Center orPopulation Health, Dartmouth Institute or HealthPolicy and Clinical Practice
Kevin Grumbach, MD, Professor and Chair, University
of California, San Francisco, Department of Family
and Community Medicine; Chief, Family and
Community Medicine, San Francisco General Hospital
Briefing document authors:
David Meyers, MD, Director, Center or Primary Care,Prevention and Clinical Partnership, Agency orHealthcare Research and Quality
Debbie Peikes, Senior Researcher, MathematicaPolicy Research
Janice L. Genevro,Ph.D., M.S.W, Lead, Primary CareImplementation Team, Center or Primary Care,Prevention and Clinical Partnership, Agency orHealthcare Research and Quality
Greg Peterson, Researcher,Mathematica Policy Research
Tim Lake, Researcher, Mathematica Policy Research
Kim Smith, Researcher, Mathematica PolicyResearch
Erin Taylor, Associate Director, health research,Mathematica Policy Research
Kevin Grumbach, MD, Professor and Chair, University
of California, San Francisco, Department of Family
and Community Medicine; Chief, Family and
Community Medicine, San Francisco General Hospital
Health ITPresenter:
David K. Nace, MD, Vice President and MedicalDirector, McKesson Corporation and member othe PCPCC board o directors
Briefing document authors:John E. Jenrette, MD, Chie Executive and MedicalOfcer, Sharp Community Medical Group
David K. Nace, MD, Vice President and MedicalDirector, McKesson Corporation
Adrienne White, M.B.A., B.S.M.T., A.S.C.P., ManagingConsultant, IBM Global Business Services, Healthcare-Practice Business Analytics and Optimization,IBM Corporation
Payment ReormPresenters:
Allan H. Goroll, MD, Proessor o Medicine, HarvardMedical School; Chair, Massachusetts Coalition orPrimary Care Reorm
Diane R. Rittenhouse, MD, M.P. H., Associate Proessor,Department o Family and Community Medicineand Philip R. Lee Institute or Health Policy Studies,University o Caliornia, San Francisco
Briefing document authors:
Thomas Bodenheimer, MD, Proessor in FamilyMedicine, University o Caliornia, San Francisco
Allan H. Goroll, MD, Proessor o Medicine, HarvardMedical School; Chair, Massachusetts Coalition orPrimary Care Reorm
Diane R. Rittenhouse, MD, M.P. H., Associate Proessor,Department o Family and Community Medicineand Philip R. Lee Institute or Health Policy Studies,University o Caliornia, San Francisco
Shawn Martin, Director o Government Relations,American Osteopathic Association
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
6/48
Christine Bechtel,Vice President,National Partnership or Women and Families
Donald Berwick, MD, M.P.P., Administrator,Centers or Medicare & Medicaid Services
Katherine H. Capps, President, Health2 Resources,Planning Committee Chair*
Blair G. Childs, Senior Vice President, Premier, Inc.
Carolyn M. Clancy, MD, Director, Agency orHealthcare Research and Quality
John B. Crosby, JD, Executive Director,
American Osteopathic Association
Gerald Cross, MD, F.A.A.F.P., Acting Under Secretaryor Health, Veterans Health Administration
Helen Darling, President, National Business Groupon Health
Karen Davis, Ph.D., President,The Commonwealth Fund
Susan Dentzer, Editor-in-Chie, Health Aairs
Allen Dobson Jr., MD, Vice President,Clinical Practice Development,Carolina Health Care System
Susan Edgman-Levitan, PA, Executive Director,John D. Stoeckle, Center or Primary CareInnovation, Massachusetts General Hospital
Elliott Fisher, MD, M.P. H., Director, Center orPopulation Health, Dartmouth Institute or HealthPolicy and Clinical Practice
Richard J. Gilfllan, MD, Director o PerormanceBased Payment Policy, Centers or Medicare &Medicaid Services
Allan H. Goroll, MD*, Proessor o Medicine,Harvard Medical School, Chair,Massachusetts Coalition or Primary Care Reorm,Massachusetts General Hospital
Kevin Grumbach, MD*, Professor and Chair, Universityof California, San Francisco, Department of Family and
Community Medicine; Chief, Family and CommunityMedicine, San Francisco General Hospital
Paul Grundy, MD, M.P. H.*, IBMs Global Directoro Healthcare Transormation; President, Patient-Centered Primary Care Collaborative
Bruce H. Hamory, MD, F.A.C.P., Executive VicePresident, Chie Medical Ofcer, Geisinger
Yael Harris, Ph.D., M.H.S., Director, Ofce oHealth IT and Quality, Health Research andService Administration
Douglas E. Henley, MD, F.A.A.F.P., Executive VicePresident and CEO, American Academy oFamily Physicians
Jim Hester, Ph.D., Director, Health Care ReormCommission, Vermont State Legislature
Sam Ho, MD, Senior Vice President and ChieMedical Ofcer, UnitedHealthcare
Christine Hunter, Rear Admiral, Deputy Director,
The TRICARE Management Activity,U.S. Department o Deense
John E. Jenrette, MD*, Chie Executive and MedicalOfcer, Sharp Community Medical Group
Peter V. Lee, JD, Director o Delivery System Reorm,Ofce o Health Reorm, U.S. Department o Health& Human Services
Kevin E. Loton, F. A.C.H.E., President and CEO,Catholic Health System
Chris McSwain, Director o Global Benefts,Whirlpool
Steven Morgenstern, Benefts Manager,Dow Chemical Company
Albert Mulley, M.P. P., MD, Chie o the GeneralMedicine Division, Director o the Medical PracticesEvaluation Center, Massachusetts General Hospital
Meeting Attendees
4
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
7/485
David K. Nace, MD*, Vice President and MedicalDirector, McKesson Corporation
Monique Nadeau, Executive Director,Hope Street Group
Patricia M. Nazemetz, Vice President and ChieEthics Ofcer, Xerox
Karen J. Nicholas, DO, MA, M.A.C.O.I., President,American Osteopathic Association
Carmen Hooker Odom, M.R.P.,President, Milbank Memorial Fund
Richard Popiel, MD, M.B.A., Vice President andChie Medical Ofcer, Horizon Blue Cross BlueShield o New Jersey
Kyu Rhee, MD, M.P.P., F.A.A.P., F.A.C.P., Chie PublicHealth Ofcer, Health Research and ServiceAdministration
Michael Rosenblatt, MD, Executive Vice President,Chie Medical Ofcer, Merck & Co., Inc.
Edwina Rogers, JD*, Executive Director,Patient-Centered Primary Care Collaborative
Lewis G. Sandy, MD, Senior Vice President,Clinical Advancement, UnitedHealth Group
Martin J. Sepulveda, MD, F.A.C.P., Vice President,Health and Well-Being, IBM Corporation
Michael S. Sherman, MD, M.B.A, MS, C.P.E, F.A.C.P.E.,Corporate Medical Director, Humana ClinicalGuidance Organization, Humana Inc.
Michael Suesserman, Vice President,
Corporate and Government Customers, Pfzer Inc.
Fan Tait, MD, F.A.A.P.*, Associate Executive Director,Director, Department o Community,Specialty Pediatrics, American Academyo Pediatrics
George E. Thibault, MD, CEO, Macy Foundation
John Tooker, MD, M.B.A., F.A.C.P.,Executive Vice President, Chie Executive Ofcer,
American College o Physicians
Jan Towers, Ph.D., NP-C, C.R.N.P., F.A. A.N.P.,Director o Health Policy, American Academyo Nurse Practitioners
Andrew Webber, President and CEO,National Business Coalition on Health
*Indicates the individual also served on the Planning Committee.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
8/48
Planning Committee
Melinda K. Abrams, MS, Vice President,The Commonwealth Fund
Thomas Bodenheimer, MD, M.P. H., Proessor,Department o FamilyandCommunity Medicine,University o Caliornia, San Francisco
Andrea Cotter, Director, Global Healthcare and LieSciences Marketing, IBM Corporation
Michael Dinneen, MD, Director, Ofce o StrategicManagement, U.S. Department o Deense
Robert Dribbon, Director, Health Care Strategy,Merck & Co., Inc.
Robert Dohert, Senior Vice President,Governmental Aairs and Public Policy,American College o Physicians
Janice L. Genevro, Ph.D., M.S.W.,Lead, Primary Care Implementation Team,
Center or Primary Care, PreventionandClinicalPartnership, Agency or Healthcare Researchand Quality
Martin Kohn, MS, MD, FACEP, FACPE, Associate
Director, Healthcare Analytics, IBM Research
Shawn Martin, Director o Government Relations,American Osteopathic Association
Karen Matsoka, D.Phil, M.Phil, Research Director,Engelberg Center or Health Care Reorm,Brookings Institute
David Meers, MD, Director, Center or Primary Care,PreventionandClinical Partnership,Agency or Healthcare Research and Quality
Kate Nehasen, MD, R-3, Resident Physician,Department o Family and Community Medicine,UCSF/San Francisco General Hospital
Dane C. Ptnam, Director, Employers Coalitions,Pfzer Inc.
Diane R. Rittenhose, MD, M.P. H., Associate Proessor,Department o Family and Community Medicine
andPhilip R. Lee Institute or Health Policy Studies,University o Caliornia, San Francisco
Rosemarie Sweene, Vice President,Public Policy and Practice Support,American Academy o Family Physicians
Adrienne White, M.B.A., B.S.M.T., A.S.C.P.,Managing Consultant, IBM Global Business Services,Healthcare Practice, Business Analytics andOptimization, IBM Corporation
Mark Zezza, Ph.D., Research Director,Engelberg Center or Health Care Reorm,Brookings Institute
6
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
9/487
Dear Colleagues:As you may know, the topic o patient-centered care is dear to my heart. I believethat, o the
six IOM Aims or Improvementsaety, eectiveness, patient-centeredness, timeliness, eciency,and equitypatient-centeredness is the keystone and that, rom it, the others properly devolve.
To me, patient-centered care is care that respects each person as an individual, honoring his
or her backgrounds, their amilies and their choices.
The Aordable Care Act calls or investments in patient-centered care, including medical and
health homes and accountable care organizations (ACOs) so patients can receive seamless,
integrated care. At the Centers or Medicare and Medicaid Services (CMS), we intend to build on
the current oundation o medical and health homes and optimize their scope o services, capacity
and capabilities or patients. We will be working to incorporate patient-centered medical homes
with ACOs and examining various payment methods to support medical home expansion through
the CMS Center or Medicare and Medicaid Innovation (Innovation Center). Along with health
homes and ACOs, the Innovation Center will be tasked with evaluating the eect o the advancedprimary care practice model, commonly reerred to as the patient-centered medical home,
in improving care, promoting health, and reducing the cost o care provided to Medicare
beneciaries served by Federally Qualied Health Centers.
One thing is or surewe cannot do this alone. It is only through partnership with the private
sector that we will accomplish our aims or integrating care. We look orward to working
with you in the uture.
Sincerely,
Donald M. Berwick, MD
Administrator
Centers or Medicare and Medicaid Services
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
10/488
What do you want health care to become?was the question that opened discussionamong a group o national thought leaders as-sembled on Sept. 8, 2010 in Washington, D.C. The
answer to this question became the ramework or
a daylong discussion led by moderator Susan
Dentzer and hosted by The Commonwealth Fund,
the Patient-Centered Primary Care Collaborative
and the Dartmouth Institute.
Almost eight months in planning, the journey to
the September 8 meeting began during a conver-
sation between Paul Grundy, MD, and White Househealth reorm policy sta during a roundtable
discussion on Aug. 10, 2009. The meeting show-
cased the evidence and outcomes1 rom patient-
centered models o care that are transorming
health care delivery. Those assembled recognized
that activity around the patient centered medical
home should ocus not only on the Joint Principles,
but on value-driving elements that would bring
about long-term, sustainable changes, with primary
care as a oundation. As a ollow up to that meet-
ing, the PCPCC brought in Health2 Resources,
which ormed a planning committee to oera structure, outline an approach and manage
a consensus meeting o engaged stakeholders.
Funding to support the eort was secured rom
Pzer, and Paul Grundy invited The Commonwealth
Fund and Dartmouth to serve as co-sponsors.
On May 4, 2010, Health Aairsheld a brieng at the
National Press Club to introduce its special issue,
Reinventing Primary Care. The issue was entirely
devoted to the topic o advanced primary care
models, making important links about value-driving
elements o the medical home and the role o
primary care within accountable care organiza-
tions. Recognition among thought leadership came
quickly that the medical home must operate in the
1 These outcomes are summarized in the PCPCC document,
Outcomes o Implementing Patient Centered Medical Home
Interventions: A Review o the Evidence rom Prospective EvaluationStudies in the United States. http://www.pcpcc.net/content/pcmh-
outcome-evidence-quality.
greater context o ACOsthe medical home situ-ated and unctioning within a medical neighbor-
hood. As CMS moved orward with its new charge
to rapidly advance promising primary care-based
models, it became clear that those supporting
primary care must also move orward to create a
consensus around key principles in this new context
Working rom a set o clearly enunciated goals, a
planning committee o thought leaders, researchers,
academics and ederal health agency leadership
began meeting weekly or what became known
as the September 8 Consensus Meeting. The desire
o the group was to build a broad consensus on
the oundation established by the Joint Principles
o the medical home, but to bring them to action
so consensus points can be used to create value
or those who purchase health care and or those
who deliver it within accountable care organizations
The patient centered medical home is an approach
to providing comprehensive primary care that
acilitates partnerships between individual patients
and their personal physicians and, when appropriate
the patients amily. ACOs, value-based insurance
design and multi-payer patient centered medical
home demonstrations must synchronize their eorts
in order to create a sustainable, long-term solution
to health care cost, quality, accountability and
access issues.
Preace
The desire o the group was to build
a broad consensus on the oundationestablished by the Joint Principles o
the medical home, but to bring them to
action so consensus points can be used
to create value or those who purchase
health care and or those who deliver it
within accountable care organizations.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
11/489
Each week during an hour-long call, the planningcommittee convened and discussed progress
toward the meeting. A host o academic and key
thought leaders spent many volunteer hours to
develop background papers that illuminated each
o the our value-driving topic areas the group
agreed to explore in detail, within the ramework
o developing consensus and action steps to drive
them orward within medical homes and ACOs:
Better care coordination1.
Better access to care (access as it relates2.to time, location, availability, etc.)
Better technology (patient portals, online3.
access to clinicians, health IT or quality
measurement)
Better payment models (designed to4.
achieve accountable, high quality,
patient-centered care)
Susan Dentzer, editor-in-chie o Health Aairs, wasinvited to serve as meeting moderator, and she
generously volunteered her time to the eort. We
also asked Dr. Donald Berwick, administrator o the
Centers or Medicare & Medicaid Services, to
discuss a vision or patient-centered care.
We are grateul or the signicant work o Susan
Dentzer and the planning committee members
as they conducted research, developed the
papers and presentations, brieed participants
prior to the meeting, and worked to activate
and engage ederal agency partnerships
around the meetings goals.
And nally, we are most thankul to PCPCC
President Paul Grundy, MD, whose sustaining
energy has sparked all our imaginations.
The initial goal to involve 35 national thought leaders
morphed to nearly 50 seated around the consensus
table on September 8, with additional sta and
planning committee members in attendance verymuch lling the room. Interest in the meeting topics
accelerated over the months o planning; it was
so overwhelming that we were orced to limit the
number o attendees to ensure robust discussion.
At the end o the day, we all let the September 8
Consensus Meeting sharing Don Berwicks passion
or the need to buy journeys, recognizing that the
value o the trip is entirely based on our own invest-
ment in it. The who, what, where and how state-
ments we use to populate the coming journey is
work still ahead o us. This document is a rst stepin drawing the roadmap we will use to navigate
that journey around policy, practice and research.
The broad set o consensus agreements and the
specic recommendations outlined over the course
o the meeting are presented here as action items
so they do not sit on a shel and become mere
mementos o the trip. There are research and
evaluation goals to be pursued, policies to be
championed, and models to be tested and
disseminated. The next leg o the journey
begins today.
Katherine H. Capps
President, Health2 Resources
Planning Committee Chair
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
12/4810
Introduction
The U.S. health care system is in crisis. Healthcare spending in the U.S. dwars that o otherindustrialized nations and threatens our ragileeconomy. The Institute o Medicine highlights the
chasm between the quality o care we receive
and the quality we should expect. Millions o
Americans have no health insurance, and the
rolls o the uninsured are rapidly expanding.
The ederal Aordable Care Act (ACA), passed
in March 2010, was a herculean attempt not only
to expand and reorm health insurance, but also to
drive quality improvements and decrease spending
in health care. It is not surprising that the processthat led to its passage was tumultuous. Health care
is not only a massive industry consuming roughly 17
percent o our gross domestic product, but it is also
deeply personal. Every person wants to be assured
that they will have easy access to the care they
need, when they need it, rom a team o providers
dedicated to maximizing their health and well-
being. Meanwhile, as a society, we must nd a
way to increase the value o health carebetter
access and quality at lower costsand this will not
be accomplished by tinkering around the edges.
A major overhaul is required. The health carereorm debate over the past many months has
been at once reasonable, rational, emotional
and divisive.
Truly remarkable was the emergence rom the tumult
o two widely endorsed models o delivery system
reorm: the patient centered medical home and the
accountable care organization. These models, taken
together, hold promise to alter the course o the U.S.
health care system. This report provides action items
to propel these initiatives orward.
The patient centered medical home (PCMH)
emphasizes the central role o primary care and
care coordination, with the vision that every person
should have the opportunity to easily access high
quality primary care in a place that is amiliar and
knowledgeable about their health care needs and
choices. The accountable care organization (ACO),
also coined the medical neighborhood, empha-
sizes the urgent need to think beyond patients to
populations, providing a vision or increasedaccountability or perormance and spending
across the health care system.
Embodied in the ACO and PCMH is a shared vision
or high-value health care in the U.S. The bipartisan
support or inclusion in the ACA refects a consensus
that the system is broken and something can,
and must, be done to x it. The models build on
decades o research and experience in a variety
o practice settings and communities. Neither
model dictates an ideal size or type o organiza-
tional setting, and it is not yet known exactly howthe models should be operationalized in any
particular setting.
But time and tide wait or no man.
Implementation is well underway, supported by a
broad-based coalition o health care stakeholders
rom the public and private sectors. Evaluations
o early initiatives demonstrate improvements in
health outcomes and patient experience, with
decreases in total expenditures. A new Center
or Medicare & Medicaid Innovation has beenestablished and charged with implementing ACO
and PCMH demonstration projects. The Oce o
the National Coordinator or Health Inormation
Technology, through the HITECH Act, has issued
Meaningul Use criteria and has dedicated money
to states and communities or implementation o
health inormation technology aimed at improving
population health outcomes. State governments
are experimenting with the models, with an eye
Every U.S. community can beneft
rom expanded access and improvedcare coordination spurred by health
inormation technology and paymentreorms. The question is where and
how to begin.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
13/4811
toward preparing the delivery system or plannedMedicaid expansions. Private health care ounda-
tions are supporting community-based demonstra-
tions and evaluations to urther our collective
knowledge base. All the major national health
plans have PCMH demonstrations underway, and
the ederal government has adopted the PCMH
model within the Department o Deense and the
Veterans Administration. A large ederal demonstra-
tion project is targeting PCMH implementation in
ederally qualied health centers. Large and small
physician practices across the country are looking
or guidance on what these models mean orthem, and where and when to begin the process
o transormation.
This report presents action items or moving orward.
The product o multi-disciplinary discussion and lively
debate, the report delves beyond the boundaries
o specic delivery system models and addresses
undamental themes essential to improving care
and stemming rising costs. It presents recommenda-
tions or immediate action by stakeholders ranging
rom policymakers to providers and researchers.
The themes, or value-driving elements, that are
the ocus o this report are access, care coordina-
tion, health inormation technology and payment
reorm. The rst two are elements o health care
delivery that require urgent overhaul to maximize
health outcomes at lower costs. The latter two are
essential tools, without which widespread imple-
mentation o new care delivery models will not
succeed. These are not the only elements o our
current health care system that require attention,
but progress in each o these areas is necessary to
optimize value in health care. Every U.S. community
can benet rom expanded access and improved
care coordination spurred by health inormation
technology and payment reorms. The question is
where and how to begin.
Enhanced Access and Care Coordination
Enhancing access means increasing access
to health care in ways that add value by
improving both the quality and eciency ocare delivery. Care coordination is aimed at
improving the transer o patient care inorma-
tion, and establishing accountability by clearly
delineating who is responsible or which aspect
o patient care delivery and communication
across the care continuum. There is substantial
evidence that enhanced access and im-
proved care coordination result in improved
health outcomes and patient satisaction,
and decreased total costs o care or a
dened population.2
The presentations highlighted specic actions to
enhance access that have been shown to add
value, including o-hours access to primary care
to decrease reliance on the emergency depart-
ment; access to same-day or next-day primary
care appointments; access to appointments with
a personal clinician who is amiliar and knowl-
edgeable about the patient and his or her needs
and preerences; expanded modes o communi-
cation between patients and providers, including
advice lines, telephone appointments, electronic
visits and interactive websites; and special atten-tion to the needs o vulnerable patient popula-
tions who may ace time constraints, language
barriers or problems with transportation. Specic
actions that dene care coordination were also
discussed, including regularly assessing care
coordination needs; creating and updating
a proactive plan o care; emphasizing communi-
cation; acilitating transitions; connecting with
community resources; and aligning resources
with population needs.
Enhanced access and care coordination are
included in the core principles o the PCMH
model, and both are essential to the success o
any ACO that aims to improve health outcomes
2 Grumbach, K. and Grundy, Paul. Outcomes o Implementing
Patient Centered Medical Home Interventions: A Review o the Evidence
rom Prospective Evaluation Studies in the United States. Patient-Centered Primary Care Collaborative 2010. Accessed at http://www.
pcpcc.net/content/pcmh-outcome-evidence-quality.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
14/4812
or a dened population at lower total costs.
This report summarizes the evidence base be-
hind enhanced access and care coordination;
describes the implementation opportunities
and challenges or both PCMHs and ACOs;and presents action items to begin to answer
important questions such as: What is the role
o primary care teams in enhanced access
and care coordination? and How can incen-
tives be aligned to drive excellence in access
and care coordination across all aspects o
the health care system?
Inormation Technology andPayment Reorm
Transormation o the U.S. health care systemto deliver greater value could be stimulated
by rapid advancements in two areas: wide-
spread implementation o health inormation
technology, and undamental reorm o the
payment system or primary care services.
While neither alone is sucient, both are
necessary to catalyze major delivery system
reorm. Electronic tools can acilitate, or
example, secure messaging, reerral manage-
ment, shared decision support, and peror-
mance reporting, the presenters explained.
Payment reorms can create nancial incen-tives to, or example, improve care coordina-
tion across settings; implement electronic visits
and expand ater-hours primary care access;
and minimize inappropriate use o costly
interventions. This report provides a review o
the challenges and opportunities or progress
in health IT implementation and payment
reorm; their relevance to the success o
PCMHs and ACOs; and action items to
acilitate progress in these areas.
The PCMH and ACO models incorporate the best
evidence and the best ideas to drive value in the
health care system. But the orward momentum
propelling these models cannot be explained by
new ideas or new evidence alone. What is historic
is the magnitude o the collaboration, the broad
inclusion o a wide variety o stakeholders, and the
diverse and dedicated leadership that spans the
private and public sectors and hails rom every
corner o the health care sector. Much o this
success can be attributed to the hard work by
leaders at the Patient-Centered Primary Care
Collaborative, the Dartmouth Institute, and The
Commonwealth Fund. Bravo or putting us all in
a room together and challenging us to communi-cate across traditional boundaries, to innovate,
investigate and leadalways keeping the patient
at the center. Responsibility or achieving greater
value in health care belongs to all o us. The action
items agreed upon at the September 8 Consensus
Meeting and detailed in this report provide much
needed direction. The time to act is now.
Diane R. Rittenhose, MD, M.P.H.
Associate Proessor
Department o Family and CommunityMedicine and Philip R. Lee Institute or
Health Policy Studies
University o Caliornia, San Francisco
November 2010
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
15/48
Creating Value: EnhancedAccess to Medical Homesand Implications for ACOs
p r e s e n t e d b y
Karen Davis, Ph.D.,
president,
The Commonwealth Fund
Value Driving Elementsof Health Reform
This paper summarizes a brie prepared by Melinda K. Abrams, MS,
and a team at The Commonwealth Fund 3
Karen Davis, Ph.D., opened the Access topicsession with the observation that the goals othe Triple Aim (improved health or the population,
improved care or the patient and reducing the
per capita cost o care) are served by advancing
access to needed health care delivery. Quoting
PCPCC President Paul Grundy, MD, Davis pointed
out that there is consensus on what shouldhappenwith patient access to care, but there is a shortall in
executing the actions needed to makeit happen.
Seventy-three percent o Americans report having
diculty obtaining timely access to their doctor,
according to a 2008 Commonwealth Fund survey.
Access issues identied by those surveyed included
getting an appointment with a doctor the same or
next day when sick, without going to the ER; getting
advice rom the doctor by phone during regular
oce hours; and getting care on nights, weekends,
or holidays without going to the ER. Health insur-ance access issues, while important to our nations
overall health, are not included in this discussion o
access in patient centered medical home and
ACO models o care delivery.
Davis oered three answers to the question o
how to change problems with access:
1. We need to get out o denial about the
U.S. health system and realize there is a gap
between what we are achieving and what
is possible.
2. Incentives need to change (e.g., payment
reorm, transparency, public recognition).
3. We need the know-how about howto change.
3 M. K. Abrams, G. Lawlor, S. C. Schoenbaum, K. Davis, Creating
Value: The Importance o Enhanced Access to Medical Homes andWhat it Means or Accountable Care Organizations, The Commonwealth
Fund, orthcoming.
13
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
16/48
PCMHs, ACOs and accessImproving patient access to primary care is central
to improving the quality and eciency o health
care. It can create greater value or patients,
providers and payers.
The evidence is consistently positive: When patients
have access to primary care, preventive services
increase, immunization rates improve, emergency
department visits and inpatient hospitalizations
decline and health care costs decrease.4,5
In the medical home, enhanced access to care
can include a variety o attributes; Davis discussed
six important ones:
1. Off-hours coverageWhen patients cannot reach or see their primary
care provider during o-hours, they tend to go to
the emergency department or seek an alternate
clinician, which can increase ragmentation and
4 J. M. Ferrante, B. A. Balasubramanian, S. V. Hudson, B. F.
Crabtree. Principles o the patient-centered medical home andpreventive services delivery,Ann Fam Med. Mar-Apr 2010;8(2):108-
16.
5 B. Starfeld, L. Shi, J. Macinko, Contribution o primary care to
health systems and health, Milbank Q,2005;83(3):457-502.
compromise quality o care. An estimated 40 to
50 percent o emergency department visits are
or non-urgent conditions, representing wasteul
health care expenditures.6 Davis relayed her
own story o sitting in an ER or hours becauseher doctor wasnt available.
When primary care providers have arrangements
or o-hours coverage, which is the expectation
o a medical home, the evidence shows reduct-
ions in emergency department use, increased
clinician satisaction and improvements in
patient experience.7, 8, 9
6 J. M. OConnell, J. L. Stanley, C. L. Malakar, Satisaction andpatient outcomes o a telephone-based nurse triage service, ManagCare, Jul 2001;10(7):55-6, 59-60, 65.
7 L. Huibers, P. Giesen, M. Wensing, R. Grol, Out-o-hours care in
western countries: assessment o dierent organizational models,
BMC Health Serv Res, Jun 2009, 23;9:105.
8 C. J. van Uden, R. A. Winkens, G. Wesseling, H. F. Fiolet, O.C. van
Schayck, The impact o a primary care physician cooperative on thecaseload o an emergency department: the Maastricht integrated
out-o-hours service, J Gen Intern Med, 2005 Jul;20(7):612-7.
9 S. Belman, V. Chandramouli, B. D. Schmitt, S. R. Poole, T. Hegarty
A. Kempe, An assessment o pediatric ater-hours telephone care:a 1-year experience,Arch Pediatr Adolesc Med, Feb
2005;159(2):145-9.
14
Source: Commonwealth Fund Survey o Public Views o the U.S. Health Care System, 2008.
Access Problems: Three o Four Adults Have DicultyGetting Timely Access to Their Doctor
30
73
60
41
Getting care on nights, weekends, orholidays without going to ER
Getting advice rom your doctor byphone during regular ofce hours
Getting an appointment with a doctor the sameor next day when sick, without going to ER
Any o the above
Percentage reporting that it is very difcult/difcult:
0 25 50 75 100
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
17/48
O-hours coverage requires collaboration
among primary care providers. ACOs may be
able to take the lead, she said, but so ar, it
hasnt happened.
2. Same-day or next-day access
The Commonwealth Funds 2009 International
Health Policy Survey showed that one-th
o Americans report waiting six or more
days to obtain an appointment with their
primary care physician.10 Lack o timely access
to primary care can not only delay diagnosis
and treatment, but also signals a lack o
respect or patients concerns and time.
One strategy to reduce wait times or appoint-
ments is advanced access or open access.
Research suggests this approach candecrease appointment no-shows, improve
continuity o care and increase patient
and clinician satisaction.
Providing same-day or next-day appointment
scheduling requires a commitment to practice
redesign, and building the patients experi-
ence into the nancial reward system, Davis
said. That could involve explicitly tying
bonuses or value-based purchasing to
this type o access.
3. Appointments with a personal clinician
Ensuring the appointment is with the patients
personal clinician is a hallmark o continuity
o care and having a true medical home,
but only 65 percent o U.S. adults report
having an accessible personal clinician.11
When patients have access to (and continuity
with) their primary care provider, preventive
care screening rates are higher, immunization
rates are higher, emergency department
and hospital visits are ewer, health care
costs are lower and patient satisaction is
10 C. Schoen, A Survey o Primary Care Physicians in 11
Countries, 2009: Perspectives on Care, Costs, and Experiences,
2009.
11 The Commonwealth Fund Commission on a High
Perormance Health System, Why Not the Best? Results rom the
National Scorecard on U.S. Health System Perormance, 2008
(The Commonwealth Fund, July 2008).
Electronic Access to Care:Evidence Shows Improvements in Quality
Early studies suggest that electronic communication withproviders and patient access to medical records over the
Internet may improve doctor-patient communication andhelp patient sel-management
Group Health Cooperatives Access Initiative includedthe ollowing:
Secure email with MDsy
Medical record accessy
Medication refllsy
Appointment schedulingy
Discussion groups and health promotion inormationy
Results rom Group Healths Access Initiative:Patients reported better access to care (e.g., time toy
appointment, seeing personal doctor, getting needed care)
Providers reported improvements in quality o service giveny
to patients (pride in service provided)Surveys did not assess patient experience with securey
email communication or other Web services
J. D. Ralston, D. P. Martin, M. L. Anderson, P. A. Fishman, D. A. Conrad,E. B. Larson, D. Grembowski, Group health cooperatives transormation towardpatient-centered access, Med Care Res Rev, 2009 Dec;66(6):703-24.
Access to Medical Homes Reduces
Racial/Ethnic DisparitiesWhen racial and ethnic minorities have access to a medical
home, disparities in care are eliminated or substantially reduced
Access to care must accommodate needs o vulnerable
patient populations
For example, when limited English profciency patients seey
clinicians that speak the same language, they ask more
questions and report better clinical outcomes
When patients have proessional interpreters, instead o ady
hoc interpreters, they report better
communication (ewer errors, greater comprehension)
management o chronic disease
patient satisaction
ollow-up and adherence to clinical advice
A.C. Beal et al. Closing the Divide: How Medical Homes Promote Equity in HealthCare: Results From The Commonwealth Fund 2006 Health Care Quality Survey(The Commonwealth Fund, June 2007); A. C. Beal et al. Latino access to thepatient-centered medical home, J Gen Intern Med, 2009 Nov;24 Suppl3:514-20; Q. Ngo-Metzger et al. Providing high-quality care or limited Englishprofcient patients: the importance o language concordance and interpreter use,J Gen Intern Med, Nov 2007;22 Suppl 2:324-30; L. S. Karliner et al. DoProessional Interpreters Improve Clinical Care or Patients with Limited EnglishProfciency? A systematic Review o the Literature, Health Services Research,
April 2007,42:2.
15
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
18/4816
signicantly improved.12,13,14 Overall, continuity
o care with a personal clinician or care team
is associated with increased eciency and
better quality o care. In addition, providing
better, less expensive care or patients withchronic conditions is a high-yield approach
to more accountable care and the
success o ACOs.
We need to do everything we can to encourage
enrollment o patients with their patient centered
medical home, with their source o primary
care, Davis said. But ACO attribution, or assigning
a patient to a primary care provider, isnt enough
by itsel: There needs to be dialogue. Doctors
and patients need to talk to each other about
their mutual expectations and responsibilities.
4. Ability to have clinical questions answered
by telephone
Establishing dedicated telephone appointments
during oce hourswhen they are an appropriate
substitute or in-person carecan reduce patient
oce visit and costs without degrading medical
outcomes or patient satisaction.
Studies show that telephone appointments have
helped clinicians successully monitor patients
with depression, asthma and urinary tract inec-tions.15 A study o telephone care provided to
elderly men in a clinic operated by the Veterans
Health Administration showed 19 percent ewer
oce visits, 28 percent ewer hospital admissions
and shorter hospital stays, 41 percent ewer
12 A. G. Mainous, R. J. Koopman, J. M. Gill, R. Baker, W. S.
Pearson, Relationship between continuity o care and diabetes control:evidence rom the Third National Health and Nutrition Examination
Survey,Am J Public Health, 2004;94(1):66-70.
13 J. W. Saultz, W. Albedaiwi, Interpersonal continuity o care and
patient satisaction: a critical review,Ann Fam Med, 2004;2(5):44551; J. M. De Maeseneer, L. De Prins, C. Gosset, J. Heyerick, Provider
continuity in amily medicine: does it make a dierence or total health
care costs?Ann Fam Med, 2003;1(3):144-148.
14 M. J. Hollander, H. Kadlec, R. Hamdi, A.Tessaro, Increasing
Value or Money in the Canadian Healthcare System: New Findingson the Contribution o Primary Care Services, Healthcare Quarterly,2009;12(4):30-42.
15 L.L. Berry, Innovations in access to care: a patient-centered
approach, 2003.
intensive care unit days and 28 percent less
estimated total health care expenditures.16
Redesign care delivery to give physicians time in
their schedules to call patients, Davis suggested,and oer a reasonable nancial incentive to
encourage them to do it. By introducing a structure
or the activity and the reimbursement or it, we can
make the right thing to do the easy thing to do.
5. Electronic access to providers and services
Patients access to care can be vastly improved
through appropriate use o Web-based or online
health care services.
Although 58 percent o U.S. adults would like to
communicate with their physician by email, only21 percent report the ability to do so.17 But studies
suggest that electronic communication with provid
ers and patient access to medical records over the
Internet may improve doctor-patient communica-
tion and help patient sel-management.18 Patients
reported better access to care (e.g., time to ap-
pointment, seeing personal doctor, getting needed
care), and providers reported improvements in
quality o service given to patients.19
It saves time or everyone, and it lets patients and
amily members review the physicians recommen-dations at their leisure.
6. Access for vulnerable patient populations
Access to care must accommodate the needs o
vulnerable patient populations, and PCMHs appear
to help achieve this goal and make a dierence in
reducing disparities. For example, Davis pointed out
that when racial and ethnic minorities have access
to a medical home, disparities in care are eliminat-
ed or substantially reduced. I was really shocked at
16 J. Wasson, C. Gaudette, F. Whaley, A. Sauvigne, P. Baribeau, H.
G. Welch, Telephone care as a substitute or routine clinic ollow-up,
JAMA, 1992;267:1788-93.
17 S. K. H. How, Public Views on U.S. Health System Organization:
A Call or New Directions, 2008.
18 J. D. Ralston, D. P. Martin, M. L. Anderson, P. A. Fishman, D. A.Conrad, E. B. Larson, D. Grembowski, Group Health Cooperatives
transormation toward patient-centered access, Med Care Res Rev,2009 Dec;66(6):703-24.
19 ibid
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
19/4817
how much the racial and ethnic disparities in
access to care, quality o care, preventive care
were eliminated i you were given care in a prac-
tice that met the characteristics o the patient
centered medical home, she said.
For the promise o enhanced access to be realized
by all patients, including the medically underserved,
the strategies and methods applied will need to
be tailored to meet the needs o vulnerable
patient populations.
ACOs enabling enhanced access
ACOs need a strong oundation o primary care
to succeed. The patient centered medical home
is the oundation or everything that calls itsel anACO, Davis said. On that oundation, there can
be dierent models or ACOs: There are dierent
ways to build the neighborhood.
Medical home care coordination and care
management activities will enable the ACO
to realize cost savings. PCMHs can benet rom
ACO inrastructure and support (e.g., inormation
technology, data collection and reporting,
additional personnel) to help PCMHs meet
their unctional requirements.
ACOs can also enhance the elements o access
that medical homes cannot oer on their own:
ACO spport or o-hors coverage: Through
the inrastructure o an ACO, small practices
can be networked or organized to more
easily share personnel to provide ater-hours
care or their patients. Alternatively, hospital-
based sta that is part o the ACO or under
contract to it can provide telephone triage
and urgent care visit services or primary
care practices.
Facilitate online access, provide tech spport:
ACOs can deray the nancial and adminis-
trative investment to provide Web-based
services, such as electronic physician-patient
messaging, e-consultations and personal
health records. ACOs can set parameters o
how these systems can/should be organized
as well as provide the resources to monitor
whether patients access to care improves.
ACOs can help primary care sites collect,
analyze and report quality data to monitor
their perormance.
Improve access to specialt care services: In
an ACO, the complement o clinicians is held
accountable or the quality o care provided
to an entire population o patients. With such
shared responsibility, the PCMH, specialty care
providers and the ACO can work together to
set up systems and agreements to ensure
timely access to specialty care services.
ACOs and PCMHs need each other, Davis said.
The evidence demonstrates that when patients
have enhanced access to primary care services,quality, eciency and patient experience improve.
Discssion and action items
One overarching consensus item emerged early
on in discussion ater the initial presentation: Any
discussion on the application o the elements o the
PCMHwhether it be care coordination, access, use
o health IT or redesign o payment modelsmust
be ramed in the context o bothenhancing value
or the patient and bending the cost curve. Valueor the patient must be inormed by the consumer
voice. The group consensus was that these two
elements should stand as the ramework or action
going orward in all our discussion topic areas.
The discussion then ocused on what it takes within
the physician practice to provide enhanced
access. Primary care capacity is a real issue; train-
ing and project management support is needed to
help practices become high-access primary care
sites. Investments are being made now to increase
the primary care workorce, but it will take time or
the pipeline to bring those newly trained proession-
als to the eld.
The primary care workorce shortage is urther
complicated by dierences in scope-o-practice
laws across states. I each health care provider is
to work at the top o his or her license to enhance
access, clarity is needed regarding which practitio-
ner is allowed to perorm specic services.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
20/4818
Policy Action item(s):
Actively support ederal unding o1.
primary care workorce training eorts
across the ull spectrum o primary care
team members in order to ensure an
adequate and well-trained primary
care workorce.
Policies and initiatives that promote2.
ACOs and PCMHs must incentivize
innovative delivery models that ensure
superb patient access to care including
o-hours coverage, same-day or next-
day visits, telephone and electronic
access, and access to electronic
medical records.
There was considerable discussion about the role
o health plans and hospitals in enhancing access.
These entities have resources already in place that
could support physician practices, such as nurse
call lines, telephonic case management and
disease management programs and ater-hours
urgent care acilities. However, patients continue to
experience problems in accessing care. Medical
home and ACO demonstration projects mustinclude collaboration between primary care
practices and hospitals and/or health plans to
test new ways to ensure enhanced access to
primary care or all patients. These eorts will inorm
the uture development o the medical neighbor-
hood, which will be critical to the success o the
ACO. This sort o attention to enhanced access
as part o existing medical home demonstrations
would require development o the medical neigh-
borhood that takes in providers (including special-
ists, hospitals and primary care providers), payers
and consumers as collaborative partners.
In particular, there is an opportunity to re-envision
the role o the hospitalspecifcally, or hospitals to
provide support o primary sites, but not through
their emergency departments, which are not
cost-eective delivery sites or primary care.
There was considerable discussion about the
consumer voice in access and a direct challenge
to include consumers in design o demonstration
projects. Incentives need to be aligned or consum-
ers to seek care in their primary care setting, rather
than turning to more costly avenues or care.
Cultural dierences also play a role in whereand how consumers seek care.
Demonstration Project Action Item(s):
1. Develop design principles to set up
systems to enable more efcient and
coordinated use o a communitys
existing access resources (e.g., call-in
lines, urgent care). Encourage collabo-
ration between health plans, hospitalsand primary care sites to reconfgure
existing resources in order to support
patients timely and appropriate
access to their patient centered
medical homes.
2. Develop a reimbursement ramework
o enhanced access that is both
patient-centered and low-costin the
ambulatory settings (whenever appro-
priate) and where it will best beneft
the patient.
3. Involve consumers in design o all
projects, but especially those that seek
to enhance access, since it is an issue
o paramount concern and interest to
patients. Keep in mind Davis directive
to make the right thing to do the easy
thing to do.
I primary care providers are to take on new access
pointstelephonic and online consultation and
ater-hours care among themmetrics and incen-
tives should be aligned to ensure that bettercare
is being delivered, not just morecare. There is an
essential need or unctional operational metrics
to understand what constitutes access. There
is urther need to refne metrics to identiy and
monitor appropriate vs. bad access.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
21/4819
Once this ramework is determined, there is a need
to assign which caregivers constitute the access
team and to dene the role and unction or each
team member. Best practices in improved access
are in the eld, but the elements o access thatmake these practices successul need urther
analysis and documentation.
Research Action Item(s):
1. Set up a research/learning collaborative
to capture learnings on improving prima-
ry care bandwidth to expand access
and to cull lessons rom existing
demonstrations.
2. Identiy the ramework or access (what
needs to be done to achieve access),
and then move to the roles and unctions
o team members (who needs to do it).
3. Develop unctional operational metrics
or appropriate access.
Melinda Abrams, MS, Vice President,
The Commonwealth Fund
Georgette Lawlor, Program Associate or
Patient-Centered Coordinated Care,
The Commonwealth Fund
Steve Schoenbam, MD, M.P.H., Executive Vice
President or Programs, The Commonwealth Fund
Karen Davis, Ph.D., President,
The Commonwealth Fund
PLANNING COMMITTEE CHAIR
Katherine H. Capps, President, Health2 Resources
The original Access briefng document or the Sept. 8, 2010 Consensus Meeting can beobtained rom The Commonwealth Fund and was prepared by:
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
22/48
Creating Vale:
Better Care Coordination
p r e s e n t e d b y
Elliott S. Fisher, MD, M.P.H.,director, Center or Population Health,Dartmouth Institute or Health Policy
Kevin Grmbach, MD,proessor and chair, UCSF Departmento Family and Community Medicine
Fisher and Grumbach credited davi M, Md, director,Center or Primary Care, Prevention and Clinical Partnership at
the Agency or Healthcare Research and Quality, orplaying a major role in the papers development.
20
Care coordination is the deliberate organization
o patient care activities between two or more
participants (including the patient) involved
in a patients care to acilitate the appropriate
delivery o health care services.20
The eective coordination o a patients healthcare services is a key component o high-quality,ecient care. It provides value to patients, proes-
sionals and the health care system by improving the
quality, appropriateness, timeliness and eciency o
decision-making and care activities, thereby aect-
ing the experience, quality and cost o health care.
But care coordination is largely missing rom the
status quo. And so Kevin Grumbach, MD, beganthe session on Care Coordination with a stark
but unsurprising assessment: The health care
system is ailing due to a lack o integrated,
coordinated care.
Care coordination has two key operational principles
he explained: the transer and exchange o inorma-
tion, and accountability. The ormer involves the
appropriate fow o inormationsuch as medical
history, medication lists, lab results, imaging studies
and patient preerencesrom one participant in a
patients care to another (including the patient).
The latter, accountability, requires clarity about the
responsibility o participants in a patients care or
each aspect o that care, e.g., speciying who is
primarily responsible or key care delivery activities,
the extent o that responsibility, and when that
responsibility will be transerred to other care partici-
pants. And it means engaging patients to develop
care plans that are accountable to the patient
and the care team.
20 McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Krat S,McKinnon M, Paguntalan H, Owens DK. Care coordination. Vol 7 o:
Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closingthe quality gap: A critical analysis o quality improvement strategies.
Technical Review 9 (Prepared by Stanord-UCSF Evidence-Based
Practice Center under contract No. 290-02-0017). AHRQ PublicationNo. 04(07)-0051-7. Rockville, MD: Agency or Healthcare Research
and Quality. June 2007.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
23/48
Care coordination and primary careCare coordination is an essential component o
primary care. As conceptualized by the Institute
o Medicine, primary care consists o the provision
o accessible, comprehensive, longitudinal andcoordinated care in the context o amilies and
community.21 More simply, it is the our cardinal
Cs: rst contact, comprehensive, continuity
and coordination.
In this conceptual model, primary care serves a
critical integrating unction or the diverse services
a patient may need, promoting cohesive, whole-
person care.
The exceptional value primary care brings to health
care systems22 is due in part to the care coordination
provided by primary care proessionals and the
inormed decision-making it allows them to make.
Grumbach shared six central activities within care
coordination that enhance health care value that
were identied in the background paper:23
1. Assess patient needs. Care coordination needsare based upon a patients health care needs
and treatment recommendations, which refect
physical, psychological and social actors.
Coordination needs also are determined by
the patients lie circumstances, current healthand health history, unctional status, sel-
management knowledge and behaviors,
and need or support services.
2. Develop and update proactive plan of care.Establish and maintain a plan o care, jointly
created and managed by the patient/amily
and health care team. The plan outlines the
patients current and longstanding needs
and goals or care, and identies coordination
needs and potential gaps. It clearly identies
the roles o each participant in the patients
care. It anticipates routine needs and tracks
up-to-date progress toward patient goals.
3. Emphasize communication.Communicationmay take a number o orms (e.g., oral,
electronic, ace-to-ace, asynchronous), and
it occurs between health care proessionals
and patient/amily, within teams o health care
proessionals and across teams or settings.
4. Facilitate transitions. Share inormation amonproviders and patients when the accountabilit
or some aspect o a patients care is trans-
erred between two or more health care
entities. Transitions require transer o both
accountability and inormation.
5. Connect with community resources.Provideand, i necessary, coordinate services with
additional resources available in the commu-
nity that help support patients health and
wellness or meet their care goals.
6. Align resources with population needs.Use a systems-level approach within the
health care system to assess the needs o
populations and to identiy and address gaps
in services. Aggregating the needs assessment
conducted with individual patients is one
method that should be used to identiy the
overall populations needs. Care coordination
and eedback rom providers and patients
should also be used to identiy opportunities
or improvement.
23 Fisher, Elliott; Grumbach, Kevin; Meyers, David, et al. Unpublished,September 8, 2010 Consensus Meeting Briefng Materials on Care
Coordination: Issues or PCMHs and ACOs
21 Primary Care: Americas Health in a New Era. Washington, DC.:
National Academy o Sciences; 1996.
22 Starfeld, B., L. Shi, and J. Macinko. Contribution o Primary Care
to Health Systems and Health. The Milbank Quarterly, vol. 83, no. 5,2005, pp. 457502.
21
Value-enhancing activities
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
24/48
The integrative unctioninterpreting with patients
the meaning o many streams o inormation and
working with the patient to make decisions based
on the ullest understanding o this inormation in
the context o the patients values and preerencesis an under-recognized and under-appreciated
value o primary care. Primary care thus is integral
to coordination o care.2122,23
Finding a pathway through the
medical neighborhood
So where does the primary responsibility or these
care coordination activities lie? Some belong in
the medical home, some in the greater medical
neighborhoodthe extended health community
o specialists, hospitals and other providers.(This medical neighborhood may or may not
be a ormally constituted accountable
care organization.)
In an accompanying slide, Grumbach illustrated
how the activities can be acilitated within the
PCMH and greater medical neighborhood
(in this case, an ACO).24
23
24 Fisher, Elliott; Grumbach, Kevin; Meyers, David, et al. Unpublished,September 8, 2010 Consensus Meeting Briefng Materials on Care
Coordination: Issues or PCMHs and ACOs.
He also explained the synergistic relationship
between the neighborhood and the PCMH. There
has to be a centersome glue that holds it togeth-
er, he said, reerring to the need or the primary
care team and the patient to serve as the nucleuso care coordination.
The patient centered medical home is the center-
piece o the medical neighborhood, but its only
a piece. The medical home should be nested
within a well-unctioning medical neighborhood.
That neighborhood is an accountable system that
ensures everything that needs to happen does
indeed happen.
Patients oten need many services in addition to
primary carespecialists, home care, pharmacy,workplace, and more. It all has to t together, and
coordination is key to making this work, Grumbach
said. There is value in having care thats pulled
together and coordinated, with the patientand
ideally the medical homeat the center.
Reviewing the evidence
Research appears to support this approach to
care, as is detailed in the brieng document.25
(For a more detailed review o the research, see the
brieng documents appendix.) Recent compre-hensive eorts to strengthen primary care, including
implementation o the PCMH model by Group
Health Cooperative (which emphasized the core
coordination unctions o primary care), are dem-
onstrating improved patient experience, improved
sta experience, improved quality and reduced
emergency department and hospital utilization.26
Well-designed, targetedcare coordination inter-
ventions delivered to the right individual can
improve patient, provider and payer outcomes,
especially when embedded in or closely articu-
lated with the patient centered medical home.27
25 Fisher, Elliott; Grumbach, Kevin; Meyers, David, et al. UnpublishedSeptember 8, 2010 Consensus Meeting Briefng Materials on Care
Coordination: Issues or PCMHs and ACOs.
26 Reid, RJ et al. The Group Health Medical Home at Year Two: Cost
Savings, Higher Patient Satisaction, and Less Burnout or Providers
Health Aairs, 2010; (29(5):835-843.
27 Ibid.
22
Care Coordination Activities Determine and update care coordination needs
Create and update a proactive plan o care
Communicate:
Between health care proessionals & patients/amily
Within teams o health care proessionals
Across health care teams or settings
Facilitate transitions
Connect with community resources
Align resources with population needs ACO
pCMH
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
25/4823
For patients with chronic conditions, particularly
those at relatively high risk o poor outcomes,
what appears to work best, Grumbach and Fisher
suggested, is the inclusion o a designated person
oten a nurse or social workerwho plays a target-ed care coordination role.
Some targeted care coordination team-based
models have been shown to improve health out-
comes and/or reduce hospitalizations, readmissions
and/or costs. In the studies reviewed, hospitalization
rates dropped between 8 percent and 46 percent.28
All successul models o care coordination have
incorporated someor oten, more extensiveace-
to-ace interaction between patients and care
coordinators to establish and maintain personal
relationships. As reported in the backgrounddocument,29 almost all successul models o target-
ed care coordination have also incorporated some
ace-to-ace interaction between the designated
care coordinators and clinicians.
Not all care coordination programs have been
shown to be eective. For example, targeted care
coordination interventions have been shown to
be successul or high-risk/high-need patients.30,31
However, these services provided to low-risk
Medicare patients have not been shown to
improve the quality o care or utilization, andat times have increased overall costs.32,33
28 Ibid.
29 Ibid.
30 Peikes, Deborah, Arnold Chen, Jennier Schore, and Randall
Brown. Eects o Care Coordination on Hospitalization, Quality o Care,
and Health Care Expenditures Among Medicare Benefciaries: 15Randomized Trials. JAMA. 2009, vol. 301, no. 6: 603-618.
31
Peikes, Deborah, Greg Peterson, Jennier Schore, CarolRazafndrakoto, and Randall Brown. Eects o Care Coordination on
Hospitalization, Quality o Care, and Health Care Expenditures AmongMedicare Benefciaries: 11 Randomized Trials. Drat manuscript,
2010.
32 Counsell SR, Callahan CM, Clark DO, et al. Geriatric care
management or low-income seniors: a randomized controlled trial.
JAMA. 2007;12;298(22):2623-33.
33 Counsell, SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost
Analysis o the Geriatric Resources or Assessment and Care o EldersCare Management Intervention. Journal o the American GeriatricsSociety. 2009; 57(8): 1420-1426.
In addition, disease management services provided
primarily by telephone have not been shown to be
eective or Medicare beneciaries.34
Bridging the PCMH, ACO perspectives:
Integrated care
Care coordination is a core activity o the patient
centered medical home. Using proactive care
teams, primary care medical homes are able to
both coordinate care with and or patients, and
use the results o eective coordination to develop
appropriate care plans. For most patients in a
primary care practice, the medical home team
which might contain nurses, pharmacists, physicians,
medical assistants, educators, behavioralists, social
workers, care coordinators and otherstakes thelead in working with the patient to dene care
needs, and to develop and update a plan o care.
The PCMH team is also responsible or ensuring
communication with patients and amilies and
across the primary care team. The PCMHs responsi-
bility includes collaborating with proessionals and
teams in other settings that participate in a given
patients care, including at points o care transitions.
The PCMH should also be involved in connecting
with community resources and aligning
those resources.
For accountable care organizations, care
coordination is critical to achieving high-quality
and high-value care. Building upon the care
coordination eorts o PCMHs, ACOs can ensure
and incentivize communication among teams o
providers operating in varied settings. Additionally,
ACOs can acilitate transitions and align resources
to meet the clinical care and care coordination
needs o populations. This work includes, but
extends beyond, creating hospital discharge
care coordination programs, to creating a medical
neighborhood where providers share inormation
with one another. ACOs can ensure that the
appropriate transitions o accountability happen
and that specialty teams are ready, willing and
able to provide the requisite services. ACOs can
34 Esposito, D., J. Schore, R. Brown, A. Chen, R. Shapiro, A.
Bloomenthal, and L. Gaber. Evaluation o Medicare DiseaseManagement Programs: LieMasters Interim Report o Findings.
Princeton, NJ: Mathematica Policy Research, February 19, 2008.
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
26/4824
also develop and support systems or care
coordination or patients who reside in
non-ambulatory care settings.
A concept that bridges the PCMH and ACO per-spectives on care coordination is integrated care.
Integrated health care starts with good primary
care and reers to the delivery o comprehensive
health care services that are well coordinated with
good communication among providers; includes
inormed and involved patients; and leads to
high-quality, cost-eective care. At the center o
integrated health care delivery is a high-perorming
primary care provider who can serve as a medical
home or patients.35 As this denition indicates,
a well-unctioning primary care medical home
is a necessary component o integrated carebut, alone, it is not sucient. True integration also
requires a cohesive medical neighborhood.
Moving ahead: organizing principles
Elliott Fisher, MD, M.P.H., then identied what he and
Grumbachand the authors o the background
paper36consider the organizing principles or
care coordination in PCMHs and ACOs.
First, care coordination is an essential unction o
primary care and the PCMH. To be successul andsustainable, PCMHs require resources that enable
care coordination, including health IT and appropri-
ately trained sta or team-based models, as well
as payment models that compensate PCMHs or
the eort devoted to care coordination activities
that all outside the in-person patient visit.
All patients have care coordination needsand
benet rom receiving appropriate coordination,
but those with complex health needs probably
have the greatest need and benet the most.
Eective care coordination involves the ability to
meet the care coordination needs o all patients
through appropriate assessment, and ecient care
35 Aetna Foundation, Program Areas: Specifcs. 2010.
(Accessed 8/2/10, at http://www.aetna.com/about-aetna-insurance/aetna-oundation/aetna-grants/program-area-specifcs.html.)
36 Fisher, Elliott; Grumbach, Kevin; Meyers, David, et al. Unpublished,September 8, 2010 Consensus Meeting Briefng Materials on Care
Coordination: Issues or PCMHs and ACOs
coordination directs more intensive and personal-
ized services to those with the greatest needs.
Patients requiring complex care rom multiple
providers oten need enhanced coordination oservicesand these services may require the
support o skilled care coordinators who work
closely with patients, amilies and clinicians.
Evidence suggests that care coordinators should
be supported in having ace-to-ace contact with
patients to help build trust. Comprehensive care
coordinators can be integrated into PCMH primary
care teams. Coordinators who operate outside o
the PCMH oce should develop close and strong
relationships with the PCMH team. ACOs should
develop additional care coordination programs
or other settings, such as hospitals.
ACOs have the potential to improve care coordina-
tion by creating the contextto support medical
homes with a strong oundation in primary care.
ACOs can provide incentives and structures that
ensure coordination and cooperation across care
teams and settings, and they should be able
to align resources to meet population care
coordination needs.
Care coordination interventions, in both PCMHs
and ACOs, must be designed to refect thestrengths and needs o local communities.
Mltiple models are likel to emerge, and both
PCMHs and ACOs shold be evalated and the
reslts shared widel. Learning rom the experiences
in place about what works and what doesnt work
is crucial to multiplication o successul models.
Begin thinking about levers and metrics
Fisher then began the transition to the group
discussion with an action-oriented question:
As we think about the discussion and our work
o the day, what are the levers we can identiy
or public payers, private payers, participants in
the health care system?
He encouraged participants to think in terms o the
Triple Aim (improve the health o the population;
enhance the patient experience o care; and
reduce, or at least control, the per capita cost o
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
27/48
care) as the overarching goal, and care coordina-
tion as one o the activities that will help achieve
that goal.
In that context, there are multiple levers, he noted,including quality measurement levers, to let us
know i we are making a dierence, reimbursement
incentives to support enhanced care coordination,
and other policy levers such as regulatory issues,
workorce issues and o course, the research.
Metrics, too, are crucial, he said. Fisher briefy
discussed a National Quality Forum model that
looks at patients across the continuum o care
needs (at-risk, acute, post acute, etc.) and shows
where the system reaches in or out to the patient.
Perormance measurement or care coordination
is part o a larger NQF project or developing a
measurement ramework or evaluating eciency,
and ultimately value, across patient-ocused
episodes o care. The ramework could help identiy
critical gaps in quality measurement and serve as
a springboard or dening longitudinal perormance
metrics that include patient-level outcomes (e.g.,
health-related quality o lie, patient experiencewith care), resource use (e.g., quantity o services
provided to patients, true costs paid or each
service), and key processes o care (e.g., shared
decision making, patient engagement).37
It could, Fisher said, provide a oundation or
understanding whether the activities o the patient
centered medical home or an accountable care
organization are actually achieving the promise
that Don [Berwick] is asking us to step orward
and ocus on.
37 National Quality Forum: Measurement Framework: EvaluatingEfciency Across Patient-Focused Episodes o Care; http://www.
qualityorum.org/Projects/Episodes_o_Care_Framework.aspx
25
Measres o coordination: Goals of care met Care transitions managed Care plans aligned
Staing Health Getting Better Living w/Illness/Disabilit
At Risk Acte Rehab RecoverCare
Onset
pHAse 1
pHAse 2 pHAse 4pHAse 3
ActePhase
Post Acte/Rehabilitation
Phase
20
Prevention
Risks reduced
Good unction
Great care
Minimal cost
Performance Measurement:NQF Episode Measurement Framework
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
28/48
Discssion and action items
Once again, the discussion ocused on the need to
set a ramework or discussion that emphasizes both
enhanced value or the patient and the need to
eectively bend the cost curve. Value or the
patient must be inormed by the consumer voice,
and an eye must also be kept on cost containment.
On the policy ront, discussion turned to the need to
be specic about the perormance metrics that will
be used to measure care coordination. There is a
strong need or standardization or reporting across
the community, another role or policymakers in the
coming months. There is also a need to include
small and solo physician practices in development
o care coordination standards and measurement
because o the signicant challenges they ace
in implementation.
Policy Action item(s):
1. Establish a measurement set that will
delineate what outcomes can and should
be measured or care coordination.
2. Create inrastructure that supports all
physicians (including solo/small practition-
ers) to achieve care coordination goals.
There was considerable discussion about the
diculties with implementation o eective care
coordination at the primary care practice level,
which may be addressed through demonstration
projects. Care coordination in most successul
demonstration projects has taken the orm oadditional sta embedded within practices to carry
out the work. For small practices, this increased
capacity is a real-world challenge. Specic prin-
ciples and a ramework or care coordination
operations or the medical home and the primary
care-based ACO should be designed, perhaps in a
learning cooperative environment where ndings
can be collected and disseminated broadly.
There was also signicant discussion around the
role o the patient in care coordination, especially
within the ACO structure. I patients are assigned
providers under an ACO model, we may see
consumer pushback as they perceive their
choices are being made or them, rather than
in collaboration with them. There is a need or
rst principles that reinorce the power o the
primary care/patient relationship, so patients
clearly understand that their health is an asset
worth supporting collaboratively.
26
Reimbrsement polic& aligned incentives
Robst qalitmeasrement
Primar care coordination
teams, health IT, hospitaldischarge planning teams,new pament models
Attention to patient vales
and holistic measres ohealth, accontabilitacross transitions
Policy Levers for Better Care Coordination
Overarching Goals:High qalit, accessible, efcient health care or all
Spported b eective care coordination
7/30/2019 Better to Best: Value-Driving Elements of the Medical Home and Accountable Care Organizations
29/4827
Demonstration Project Action Item(s):
1. Dvop dsi picips to opatioa-
iz ca coodiatio, at th xt v o
dtai dow om th cossus pap.
2. St xpicit objctivs o ca coodi-
atio aoud th picips o Istitut
o o Hath Ca Impovmts Tip
Aim: Btt ca o idividuas, btt
hath o th commuity ad duc,
o at ast coto, th p capita cost
o ca.
3. Ivov cosums i dsi o w
ca mods to icud cost aoud
ca maamt.
Th was aso discussio about dfi what
costituts succssu ca coodiatio withi th
PCMH ad ACO. Bst pactics i ca coodia-
tio ad cas maamt a sti i ay stas
o dvopmt. Th o o th hospitaist i thca cotiuum has ot b thoouhy xpod,
ad impicatios o coodiatio o d-o-i ca
w ot addssd i th pap. Impovmt i
ths aas os th pottia ot oy o im-
povd quaity, but aso o pottia cost savis.
Research Action Item(s):
1. St up a sach/ai coaboativ
to dissmiat data ad sach om
piots.
David Meyers, MD, Director, Center or Primary Care,
Prevention and Clinical Partnership, Agency or
Healthcare Research and Quality
Debbie Peikes, Senior Researcher,
Mathematica Policy Research
Janice L. Genevro, Ph.D., M.S.W., Lead, Primary Care
Implementation Team; Center or Primary Care,
Prevention and Clinical Partnership; Agency or
Healthcare Research and Quality
Greg Peterson, Researcher,
Mathematica Policy Research
Tim Lake, Researcher,
Mathematica Policy Research
Kim Smith, Researcher,Mathematic