THE ‘MEDICAL HOME’ : THE ‘MEDICAL HOME’ : An Evolving American Strategy toAn Evolving American Strategy toProvide Comprehensive Primary HealthProvide Comprehensive Primary HealthCare to Vulnerable Patient PopulationsCare to Vulnerable Patient Populations

The Future of Primary Health Care in Europe (II)The Future of Primary Health Care in Europe (II)European Forum for Primary Care (EFPC)European Forum for Primary Care (EFPC)University of Southampton, EnglandUniversity of Southampton, EnglandMonday, 15Monday, 15thth September 2008 September 2008

Dennis L. Kodner, PhD, Professor of Medicine & Gerontology and Director, Dennis L. Kodner, PhD, Professor of Medicine & Gerontology and Director, NYIT Center for Gerontology & Geriatrics and Jamie Yedowitz,BS, OMS III, New NYIT Center for Gerontology & Geriatrics and Jamie Yedowitz,BS, OMS III, New York College of Osteopathic Medicine of New York Institute of Technology York College of Osteopathic Medicine of New York Institute of Technology (NYIT), Old Westbury, New York 11568-8000, USA — Contact:(NYIT), Old Westbury, New York 11568-8000, USA — Contact: DKodner@nyit.eduDKodner@nyit.edu

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PRIMARY CARE INNOVATION & PRIMARY CARE INNOVATION & REFORM: THE AMERICAN CONTEXTREFORM: THE AMERICAN CONTEXT

There are a number of developments and trends in the U.S. health systemThere are a number of developments and trends in the U.S. health systemthat are driving interest on the policy and practice levels in primary healththat are driving interest on the policy and practice levels in primary healthcare innovation and reform—including the ‘Medical Home’ approach:care innovation and reform—including the ‘Medical Home’ approach:

Overemphasis on specialization and specialty referrals;Overemphasis on specialization and specialty referrals;

Growing shortage of primary care physicians due toGrowing shortage of primary care physicians due to adverse practice conditions, i.e., status, low pay, adverse practice conditions, i.e., status, low pay, and overwork;and overwork;

Population aging and increasing prevalence of chronicPopulation aging and increasing prevalence of chronic diseases;diseases;

Focus on episodic care;Focus on episodic care;

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THE AMERICAN CONTEXT (THE AMERICAN CONTEXT (cont’dcont’d))

Coordination and continuity of care problems—especially Coordination and continuity of care problems—especially for patients with complex conditions and multiple needs;for patients with complex conditions and multiple needs;

Poor value for money—despite world’s costliest system; Poor value for money—despite world’s costliest system; and,and,

Archaic FFS payment methods that do not promote Archaic FFS payment methods that do not promote quality or efficiency.quality or efficiency.

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THE INTEGRATION CHALLENGE IN THE INTEGRATION CHALLENGE IN PRIMARY HEALTH CAREPRIMARY HEALTH CARE

Integration or coordination of care—initiatives at the micro, meso and Integration or coordination of care—initiatives at the micro, meso and macro levels to enable different parts of the health system to work more macro levels to enable different parts of the health system to work more effectively and efficiently together—is a major driver of concern abouteffectively and efficiently together—is a major driver of concern aboutcontemporary healthcare’s ability to address the needs of ever-contemporary healthcare’s ability to address the needs of ever-increasing numbers of people for more complex, comprehensive, and increasing numbers of people for more complex, comprehensive, and continuous care. To strengthen primary health care’s pivotal role in the continuous care. To strengthen primary health care’s pivotal role in the care enterprise, new and innovative concepts must be melded to: care enterprise, new and innovative concepts must be melded to:

Operationalize a holistic understanding of health and Operationalize a holistic understanding of health and its multiple determinants;its multiple determinants;

Emphasize health promotion/prevention andEmphasize health promotion/prevention and rehabilitation—in addition to illness treatment; rehabilitation—in addition to illness treatment;

Enhance multi-disciplinary team care and collaborationEnhance multi-disciplinary team care and collaboration across time and service setting; across time and service setting;

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THE INTEGRATION CHALLENGE IN THE INTEGRATION CHALLENGE IN PRIMARY HEALTH CARE (PRIMARY HEALTH CARE (cont’dcont’d))

Assure accessibility to needed care/services;Assure accessibility to needed care/services;

Engage and support patients/families as care Engage and support patients/families as care partners; and,partners; and,

Facilitate evidence-based clinical management: Facilitate evidence-based clinical management: “ “one-to-one” and “one-to-n”.one-to-one” and “one-to-n”.

SourcesSources: Powell Davies, 2006; Kodner & Spreeuwenberg, 2002; Wagner, 2000;: Powell Davies, 2006; Kodner & Spreeuwenberg, 2002; Wagner, 2000;Barnes, 1997; Greenlick, 1992Barnes, 1997; Greenlick, 1992

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THE ‘MEDICAL HOME’: A GENERIC THE ‘MEDICAL HOME’: A GENERIC DEFINITION OF THE MODEL DEFINITION OF THE MODEL

The ‘Medical Home’ is not a place, but rather an approach to providing The ‘Medical Home’ is not a place, but rather an approach to providing comprehensive, patient-centered primary health care. The Primary Care comprehensive, patient-centered primary health care. The Primary Care Physician (PCP) works in partnership with the patient/family to assure that Physician (PCP) works in partnership with the patient/family to assure that their medical and health-related needs are met through accessible, their medical and health-related needs are met through accessible, coordinated, culturally-sensitive care delivered on a continuous basis and coordinated, culturally-sensitive care delivered on a continuous basis and across all disciplines, settings and services in order to achieve optimum across all disciplines, settings and services in order to achieve optimum health outcomes and quality of life. To use the terminology of Geoff health outcomes and quality of life. To use the terminology of Geoff Meads, the model is part “Extended General Practice”/part “Managed Meads, the model is part “Extended General Practice”/part “Managed

Care Care Enterprise”. Essential elements include:Enterprise”. Essential elements include:

PCP with back-up from physician-directed practice staffPCP with back-up from physician-directed practice staff capable of providing/arranging/monitoring comprehensivecapable of providing/arranging/monitoring comprehensive services and managing population-based health outcomes; services and managing population-based health outcomes;

““Whole person” orientation focusing on all of the patient‘s Whole person” orientation focusing on all of the patient‘s medical/health needs and incorporating holistic methodsmedical/health needs and incorporating holistic methods with conventional allopathic interventions;with conventional allopathic interventions;

Incorporates Wagner’s Chronic Care Model;Incorporates Wagner’s Chronic Care Model;

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THE ‘MEDICAL HOME’: A GENERIC THE ‘MEDICAL HOME’: A GENERIC DEFINITION OF THE MODEL DEFINITION OF THE MODEL (cont’d)(cont’d)

Emphasis on preventive and self-care measures, includingEmphasis on preventive and self-care measures, including health coaching, behavior modification, etc.health coaching, behavior modification, etc.

Electronic Medical Record (EMR);Electronic Medical Record (EMR);

Care management—vertically and horizontally—to arrangeCare management—vertically and horizontally—to arrange and coordinate all of the patient’s medical/health care and coordinate all of the patient’s medical/health care services, as well as monitor changing personal health statusservices, as well as monitor changing personal health status and needs on a longitudinal basis;and needs on a longitudinal basis;

Evidence-based clinical decision-making;Evidence-based clinical decision-making;

Care anywhere, any time, e.g., via open scheduling, Care anywhere, any time, e.g., via open scheduling, expanded hours, group visits, telephone/email consultation expanded hours, group visits, telephone/email consultation and other innovative communications options, cyber-and other innovative communications options, cyber-

visiting,visiting, customized educational tools, and self-monitoring devices; customized educational tools, and self-monitoring devices;

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THE ‘MEDICAL HOME’: A GENERIC THE ‘MEDICAL HOME’: A GENERIC DEFINITIONDEFINITION OF THE MODEL OF THE MODEL (cont’d)(cont’d)

Technology and clinical information systems to facilitateTechnology and clinical information systems to facilitatepatient communication/monitoring, high-quality care, patient communication/monitoring, high-quality care,

practice based-learning, patient education, and quality practice based-learning, patient education, and quality improvement;improvement;

Ongoing patient engagement and feedback, and Ongoing patient engagement and feedback, and informed, activated patients;informed, activated patients;

Accountability for performance/outcomes; and,Accountability for performance/outcomes; and,

Supportive payor coverage policies, financing, and Supportive payor coverage policies, financing, and reimbursement methods/incentives.reimbursement methods/incentives.

SourcesSources: Robert Graham Center, 2007; American College of Physicians, 2006,2004; : Robert Graham Center, 2007; American College of Physicians, 2006,2004; Meads, 2006; Davis, Schoenbaum & Audet, 2005; Bodenheimer, Wagner & Grumbach, Meads, 2006; Davis, Schoenbaum & Audet, 2005; Bodenheimer, Wagner & Grumbach, 2002; Medical Home Initiatives for Children with Special Needs Project Advisory 2002; Medical Home Initiatives for Children with Special Needs Project Advisory Committee,2002; American Academy of Pediatrics Ad Hoc Task Force on Definition of Committee,2002; American Academy of Pediatrics Ad Hoc Task Force on Definition of

the the Medical Home, 2002: Wagner, 1998; Austin & Van Korff, 1996; Institute of Medicine, Medical Home, 2002: Wagner, 1998; Austin & Van Korff, 1996; Institute of Medicine, 1996; Deloitte Center for Health Solutions, n.d.1996; Deloitte Center for Health Solutions, n.d.

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IN THE BEGINNING: MEDICAL IN THE BEGINNING: MEDICAL HOMES FOR CHILDREN WITH HOMES FOR CHILDREN WITH ‘SPECIAL NEEDS’ ‘SPECIAL NEEDS’ An estimated 1-in-6 American children has a complex chronic condition—An estimated 1-in-6 American children has a complex chronic condition—physical, developmental, behavioral and/or emotional—that goes beyond physical, developmental, behavioral and/or emotional—that goes beyond the traditional medical services required by the pediatric population the traditional medical services required by the pediatric population generally. In addition to excellent primary care, these ‘special needs’ generally. In addition to excellent primary care, these ‘special needs’ patients need a wide range of therapeutic and supportive services from patients need a wide range of therapeutic and supportive services from multiple providers and service systems. Recognizing this situation, the multiple providers and service systems. Recognizing this situation, the American Academy of Pediatrics (AAP) was the first group to call on American Academy of Pediatrics (AAP) was the first group to call on pediatricians to develop Medical Homes for children (1992) with the pediatricians to develop Medical Homes for children (1992) with the following eight (8) main components:following eight (8) main components:

Provision of preventive care;Provision of preventive care;

Assurance of around-the-clock medical care;Assurance of around-the-clock medical care;

Continuity of care—from infancy through adolescence;Continuity of care—from infancy through adolescence;

Appropriate use of subspecialty consultation/referrals;Appropriate use of subspecialty consultation/referrals;

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IN THE BEGINNING: MEDICAL HOMES IN THE BEGINNING: MEDICAL HOMES FOR CHILDREN WITH ‘SPECIAL NEEDS’FOR CHILDREN WITH ‘SPECIAL NEEDS’ ((cont’d)cont’d)

Practice-based care coordination; Practice-based care coordination;

Ongoing interaction with school and communityOngoing interaction with school and community agencies; agencies;

Central medical record and database with allCentral medical record and database with all pertinent health-related information; and,pertinent health-related information; and,

Active family involvement in decision-making. Active family involvement in decision-making.

SourceSource: Medical Home Initiative for Children with Special Needs Project: Medical Home Initiative for Children with Special Needs ProjectAdvisory Committee, 2002; American Academy of Pediatrics Ad Hoc Task Force Advisory Committee, 2002; American Academy of Pediatrics Ad Hoc Task Force

on on Definition of Medical Home, 2002Definition of Medical Home, 2002

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MEDICAL HOMES FOR CHILDREN WITH MEDICAL HOMES FOR CHILDREN WITH ‘SPECIAL NEEDS’: THE EVIDENCE‘SPECIAL NEEDS’: THE EVIDENCE

AAP has pilot tested and evaluated the model in collaboration with AAP has pilot tested and evaluated the model in collaboration with a a

number of pediatric practices around the country. The results are number of pediatric practices around the country. The results are very promising. Parents of children with ‘special needs’ who have a very promising. Parents of children with ‘special needs’ who have a Medical Home report:Medical Home report:

Significantly easier access to care;Significantly easier access to care;

Significantly less delayed/forgone care;Significantly less delayed/forgone care;

Significantly fewer unmet health care needs; and,Significantly fewer unmet health care needs; and,

Significantly fewer unmet family needs forSignificantly fewer unmet family needs for support servicessupport services

SourceSource: : PediatricsPediatrics (2004), 113:5 (2004), 113:5

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A NEW TWIST: ‘GUIDED CARE’ FOR A NEW TWIST: ‘GUIDED CARE’ FOR HI-RISK GERIATRIC PATIENTSHI-RISK GERIATRIC PATIENTS

Hi-risk geriatric patients have multiple, co-occurring chronic conditions Hi-risk geriatric patients have multiple, co-occurring chronic conditions and and

functional disorders, are frail and medically/socially complex, and often functional disorders, are frail and medically/socially complex, and often need a mix of health care and supportive services to maintain need a mix of health care and supportive services to maintain

independent independent community living. Quality of care can be problematic—especially since community living. Quality of care can be problematic—especially since PCPs with expertise in geriatric medicine are in very short supply. ‘Guided PCPs with expertise in geriatric medicine are in very short supply. ‘Guided Care’—developed at Johns Hopkins Bloomberg School of Public Health in Care’—developed at Johns Hopkins Bloomberg School of Public Health in Baltimore, MD—is an innovative, interdisciplinary, Medical Home-like Baltimore, MD—is an innovative, interdisciplinary, Medical Home-like model of primary care designed to improve patient-centeredness and model of primary care designed to improve patient-centeredness and care quality/efficiency for vulnerable older people. The Guided Care modelcare quality/efficiency for vulnerable older people. The Guided Care modelintegrates several previously successful clinical interventions “under one integrates several previously successful clinical interventions “under one roof”:roof”:

Specially-trained Guided Care Nurse co-located Specially-trained Guided Care Nurse co-located with several PCPs; with several PCPs;

Electronic Health Record (EHR); Electronic Health Record (EHR); Comprehensive assessment and evidence-based Comprehensive assessment and evidence-based care planning (e.g., care guide and action plan); care planning (e.g., care guide and action plan);

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A NEW TWIST: ‘GUIDED CARE’ FOR A NEW TWIST: ‘GUIDED CARE’ FOR HI-RISK GERIATRIC PATIENTS (cont’d)HI-RISK GERIATRIC PATIENTS (cont’d)

Emphasis on patient self-management; Emphasis on patient self-management;

Ongoing care coordination and patient monitoringOngoing care coordination and patient monitoring (at least monthly);(at least monthly);

Patient coaching to promote healthy behaviors;Patient coaching to promote healthy behaviors;

Smoothing of patient transitions between providersSmoothing of patient transitions between providers and sites of care;and sites of care;

Carer education and support; and,Carer education and support; and,

Enhanced access to community resources.Enhanced access to community resources.

SourcesSources: Aliotta et al, 2008. Also: : Aliotta et al, 2008. Also: www.guidedcare.orgwww.guidedcare.org and and www.innovations.ahrq.gov/content.aspx?id=1752www.innovations.ahrq.gov/content.aspx?id=1752

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‘‘GUIDED CARE’:GUIDED CARE’: EMERGING EMERGING EVIDENCEEVIDENCE

Based on pilot study results and early findings from a multi-site, Based on pilot study results and early findings from a multi-site, randomized controlled trial (RCT), the effects of Guided Care—in randomized controlled trial (RCT), the effects of Guided Care—in

terms of terms of quality, patient/family satisfaction, and costs—appear to be quality, patient/family satisfaction, and costs—appear to be

moving in the moving in the right direction: right direction:

Pilot Study:Pilot Study:

-Patient rating of Guided Care significantly-Patient rating of Guided Care significantly higher than usual care;higher than usual care;

-Reduced hospital/ED admissions and hospital days; and,-Reduced hospital/ED admissions and hospital days; and,

-Expenses—as measured by insurance payments—were-Expenses—as measured by insurance payments—were 25% lower over a 6-month period. 25% lower over a 6-month period.

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‘‘GUIDED CARE’: EMERGING GUIDED CARE’: EMERGING EVIDENCEEVIDENCE (cont’d)(cont’d)

RCT (Early Results):RCT (Early Results):

-Patients/families were more satisfied with Guided Care-Patients/families were more satisfied with Guided Care than usual care;than usual care;

-PCPs were more likely to be satisfied with their patient/-PCPs were more likely to be satisfied with their patient/ family interactions; and,family interactions; and,

-Patients rated the quality of their health care higher than-Patients rated the quality of their health care higher than usual care.usual care.

SourcesSources: Boyd et al, 2007; Bouldt et al, 2008: Boyd et al, 2007; Bouldt et al, 2008

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MEDICAL HOMES FOR EVERYONEMEDICAL HOMES FOR EVERYONE

Over the past several years, the Medical Home concept has also found its Over the past several years, the Medical Home concept has also found its way into mainstream health care as a way to renew and reinvigorate the way into mainstream health care as a way to renew and reinvigorate the American primary care system on both the population and clinical levels—American primary care system on both the population and clinical levels—especially in the face of growing chronic illness. Multiple medical specialty especially in the face of growing chronic illness. Multiple medical specialty groups, federal/state governments, foundations and advocacy groups, federal/state governments, foundations and advocacy organizations are promoting variations on the generic model now widely organizations are promoting variations on the generic model now widely known as the ‘Patient-Centered Medical Home’: known as the ‘Patient-Centered Medical Home’:

American College of Physicians (ACP): Advanced Medical HomeAmerican College of Physicians (ACP): Advanced Medical Home www.acponline.org/advocacy/events/state_of_healthcare/statehc06_5pdfwww.acponline.org/advocacy/events/state_of_healthcare/statehc06_5pdf

American College of Family Physicians (ACFP): TransforMEDAmerican College of Family Physicians (ACFP): TransforMED www.transformed.comwww.transformed.com

Tax Relief and Health Care Act of 2006: Medical Home Demo.Tax Relief and Health Care Act of 2006: Medical Home Demo. www.cms.hhs.gov/DemProjectsEvalRpts/downloads/MedHome_TaxRelief_HealthCareAct.pdfwww.cms.hhs.gov/DemProjectsEvalRpts/downloads/MedHome_TaxRelief_HealthCareAct.pdf

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MEDICAL HOMES FOR EVERYONE MEDICAL HOMES FOR EVERYONE (cont’d)(cont’d)

National Committee for Quality Assurance (NCQA): National Committee for Quality Assurance (NCQA): Physician Practice ConnectionsPhysician Practice Connections www.ncqa.org/tabid/631/Default.aspxwww.ncqa.org/tabid/631/Default.aspx

Joint Principles of the Patient-Centered Medical Home:Joint Principles of the Patient-Centered Medical Home: AAFP, AAP, ACP and AOA AAFP, AAP, ACP and AOA www.medicalhomeinfo.org?Joint%20Statement.pdfwww.medicalhomeinfo.org?Joint%20Statement.pdf

The Commonwealth Fund: Patient-Centered Primary The Commonwealth Fund: Patient-Centered Primary Care InitiativeCare Initiative www.commonwealthfund.org/programs/programs_list.htm?attrib_id=11936www.commonwealthfund.org/programs/programs_list.htm?attrib_id=11936

Community Care of North Carolina (CCNC): Medical HomeCommunity Care of North Carolina (CCNC): Medical Home B. Steiner et al, 2008B. Steiner et al, 2008 Available atAvailable at: : www.annfammed.org/cgi/content/full/6/4/361www.annfammed.org/cgi/content/full/6/4/361

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MEDICAL HOMES FOR EVERYONE MEDICAL HOMES FOR EVERYONE (cont’d)(cont’d)

Community Care of North Carolina (CCNC): Medical HomeCommunity Care of North Carolina (CCNC): Medical Home B. Steiner et al, 2008B. Steiner et al, 2008 Available atAvailable at: : www.annfammed.org/cgi/content/full/6/4/361www.annfammed.org/cgi/content/full/6/4/361

Patient Centered Primary Care Collaborative (PCPCC)Patient Centered Primary Care Collaborative (PCPCC) www.pcpcc.netwww.pcpcc.net

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MEDICAL HOMES FOR AMERICA: MEDICAL HOMES FOR AMERICA: HOW CLOSE ARE WE?HOW CLOSE ARE WE?

To use a term coined by Clayton Christensen, the Medical Home is a To use a term coined by Clayton Christensen, the Medical Home is a ““disruptive innovation”—in a positive sense. As a potentially powerful form disruptive innovation”—in a positive sense. As a potentially powerful form of integration, it is designed to revitalize the American primary care of integration, it is designed to revitalize the American primary care system—whether for vulnerable groups or the population-at-large. Whilesystem—whether for vulnerable groups or the population-at-large. WhileMedical Home offers enormous promise, it is clear that the changes Medical Home offers enormous promise, it is clear that the changes envisioned will not happen overnight. There are a series of medium- to envisioned will not happen overnight. There are a series of medium- to long-term ‘make or brake’ challenges which must be overcome before long-term ‘make or brake’ challenges which must be overcome before becoming part of mainstream policy and practice:becoming part of mainstream policy and practice:

Firmly establish clinical/business cases:Firmly establish clinical/business cases:

-Does it really produce the impacts claimed? For-Does it really produce the impacts claimed? For some or all patient groups?some or all patient groups? -Is it robust enough?-Is it robust enough? -What does it really cost? Can we afford it?;-What does it really cost? Can we afford it?;

Educate/train physicians, nurses etc.;Educate/train physicians, nurses etc.;

Retrofit/upgrade primary care infrastructure and Retrofit/upgrade primary care infrastructure and technology;technology;

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MEDICAL HOMES FOR AMERICA: MEDICAL HOMES FOR AMERICA: HOW CLOSE ARE WE?HOW CLOSE ARE WE? (cont’d)(cont’d)

Develop access to affordable capital; Develop access to affordable capital;

Reform health care financing/reimbursement:Reform health care financing/reimbursement:

-Care coordination fee?-Care coordination fee? -Pay for Performance (P4P)?-Pay for Performance (P4P)? -Blended rate?-Blended rate? -Incentives for consumers?; -Incentives for consumers?;

Adopt certification/accreditation standards; Adopt certification/accreditation standards;

Increase supply of PCPs, Advanced Practice NursesIncrease supply of PCPs, Advanced Practice Nurses (APNs), Clinical Nurse Specialists (CNSs), and Nurse (APNs), Clinical Nurse Specialists (CNSs), and Nurse Practitioners (NPs); and,Practitioners (NPs); and,

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MEDICAL HOMES FOR AMERICA: MEDICAL HOMES FOR AMERICA: HOW CLOSE ARE WE?HOW CLOSE ARE WE? (cont’d)(cont’d)

Overcome other barriers:Overcome other barriers:

-Public Acceptance: Threat to “freedom of choice”?-Public Acceptance: Threat to “freedom of choice”? -Vested interests (e.g., specialists, disease -Vested interests (e.g., specialists, disease management/care management management/care management providers).providers).

SourceSource: Christensen, 2006: Christensen, 2006