Building an Integrated System for Personalizing Care

Tim Johnson, MDSpring, 2014

Intermountain Medical Group• 1,056 physicians

• 342 primary care• 491 secondary care• 86 hospitalists• 17 radiologists• 120 urgent care

• 265 advanced practice clinicians• 81 primary care clinics

Dual Model for the Medical Home

Distributed Model Intensive Model

Distributed Model: Personalized Primary CareIntermountain Medical Group and SelectHealth Modeled on 2011 PCMH NCQA StandardsTeam members

• Primary Care Clinician• RN Care Manager• MA Health Advocate(s)• Advanced Practice Clinicians• Doctor of Pharmacy• Mental Health Integration

Personalized Primary CareImplementation 2010 - 2014

• 64 adult primary care clinics• 17 pediatric clinics• 345 physicians and advance

practice clinicians• ~100 care managers and health

advocatesHybrid model: central and region leadershipLevel 2 and level 3 within 2-3 years

Personalized Primary Care: Results

20%

35%Intermountain diabetes bundle: HgbA1c < 8% LDL < 100 BP < 140/90 Annual nephropathy screen Eye exam every 2 years

48%

50%

52%

54%

56%

58%

60%

62%

64%2013 Stretch Goal

1 2 3

PPCsAll

Clinical Quality

Patient Satisfaction

Years after Implementation

Allowed Per Member Per Month

Total Cost Trend*

*Preliminary results, risk-adjusted and normalized for contractual payment differences

Intensive Model: Personalized Care Clinic

• An outpatient clinic that provides intensive medical, behavioral, and social management for Intermountain’s high-risk patients

• Patients in the top 5-10% of costs for 2 of the last 3 years

Personalized Care Clinic: The Team

• Internal Medicine Physician• Palliative Care Physician (0.2)• RN Care Manager• Psychiatry APRN• LCSW• Pharmacist

• 2 Medical Assistants• PSR• Clinic Manager• Assistant Region Operations

Officer• Region Medical Director

Personalized Care Clinic: Process of care

• Acts like a primary care office with more resources to coordinate care, address mental health conditions, and manage complex medication issues

• Ensure patients receive care in appropriate setting – focus on acute care utilization

• Coordinate and collaborate with all of the patient’s specialists

• Committed to eliminating all avoidable health care emergencies

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