THE PATIENT- CENTERED MEDICAL HOME Sarat Raman, MD Dept. of
Family & Community Medicine Tulane University School of
Medicine
Slide 2
OBJECTIVES By the end of this session the learner will be able
to: Discuss the need for change in the healthcare system of the US.
Describe the seven principles of the patient-centered medical home
Describe some of the proven benefits of the patient-centered
medical home Discuss the variety of locations, collaborative
partners, clinic types and health care settings that have
successfully used the patient centered medical home
Slide 3
IHI TRIPLE AIM Work to improve site-specific care for
individuals should expand and thrive. In our view, however, the
United States will not achieve high-value health care unless
improvement initiatives pursue a broader system of linked goals. In
the aggregate, we call those goals the Triple Aim: improving the
individual experience of care; [better care] improving the health
of populations; [better health] and reducing the per capita costs
of care for populations. [lower cost] Donald M. Berwick, Thomas W.
Nolan and John Whittington The Triple Aim: Care, Health, And Cost.
Health Affairs, 27, no.3 (2008):759-769
Slide 4
BETTER HEALTH RankingCountry 1France 2Italy 3San Marino 4
Andorra 5 Malta 6 Singapore 7 Spain 8 Oman 9 Austria 10 Japan
36Costa Rica 37 United States 38Slovenia 39Cuba The World Health
Report 2000 Health systems: Improving performance
Slide 5
BETTER HEALTH Of 13 [industrialized] countries in a recent
comparison, the United States ranks an average of 12th (second from
the bottom) for 16 available health indicators 13th (last) for
low-birth-weight percentages 13th for neonatal mortality and infant
mortality overall 11th for postneonatal mortality 13th for years of
potential life lost (excluding external causes) 11th for life
expectancy at 1 year for females, 12th for males 10th for life
expectancy at 15 years for females, 12th for males 10th for life
expectancy at 40 years for females, 9th for males 7th for life
expectancy at 65 years for females, 7th for males 3rd for life
expectancy at 80 years for females, 3rd for males 10th for
age-adjusted mortality Starfield B. Is US Health Really the Best in
the World?. JAMA. 2000;284(4):483-485.
Slide 6
TRAGEDY IN THE SKIES What if it happened every other day?
23,400 * 3.5 = ??? = 81,900 deaths per year # of passengers in a
747 450 Weeks in a year52 Total23,400
Slide 7
BETTER HEALTH At least 44,000 people, and perhaps as many as
98,000 people, die in hospitals each year as a result of medical
errors that could have been prevented, according to estimates from
two major studies. Even using the lower estimate, preventable
medical errors in hospitals exceed attributable deaths to such
feared threats as motor-vehicle wrecks, breast cancer, and AIDS. To
Err is Human: Building a Safer Health System, Institute of
Medicine. Sept 1999.
Slide 8
DANGER WILL ROBINSON! DANGER! US estimates of the combined
effect of errors and adverse effects that occur because of
iatrogenic damage not associated with recognizable error include:
12,000 deaths/year from unnecessary surgery 7000 deaths/year from
medication errors in hospitals 20,000 deaths/year from other errors
in hospitals 80,000 deaths/year from nosocomial infections in
hospitals 106,000 deaths/year from nonerror, adverse effects of
medications These total to 225,000 deaths per year from iatrogenic
causes. Starfield B. Is US Health Really the Best in the World?.
JAMA. 2000;284(4):483-485.
Slide 9
BETTER CARE
Slide 10
Slide 11
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
program: 2012 Clinician & Group Survey Results
Slide 12
LOWER COSTS RankingCountryExpenditure Per Capita 1France 4
2Italy11 3San Marino21 4 Andorra23 5 Malta37 6 Singapore37 7
Spain24 8 Oman62 9 Austria 6 10 Japan13 36Costa Rica50 37 United
States 1 38Slovenia29 39Cuba 118 The World Health Report 2000
Health systems: Improving performance
Slide 13
LOWER COSTS Major components of the $3.5 trillion spent in
fiscal 2010 http://www.factcheck.org/2011/07/fiscal-factcheck/
LOWER COSTS K. Davis, C. Schoen, S. Guterman, T. Shih, S. C.
Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care
Expenditures: What Are the Options?, The Commonwealth Fund, January
2007
Slide 16
THE PATIENT-CENTERED MEDICAL HOME The Patient Centered Medical
Home is a health care setting that facilitates partnerships between
individual patients, and their personal physicians, and when
appropriate, the patients family. Care is facilitated by
registries, information technology, health information exchange and
other means to assure that patients get the indicated care when and
where they need and want it in a culturally and linguistically
appropriate manner.
http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
Slide 17
WHY OUTPATIENT? N England Journal of Medicine
2001;344:2021-25]: A typical month of health care in the United
States
Slide 18
HISTORY OF THE PCMH 1967 AAP introduces the term medical home,
which described a single source of medical information about a
patient 1978 - WHO made the Alma Ata declaration describing the
importance of primary care. This also laid some of the basic tenets
in language that is now used to describe the PCMH 1990s IOM begins
mentioning the medical home 2002 The Future of Family Medicine
Collaborative every American should have a Personal Medical Home
that serves as the focal point through which all individuals
regardless of age, sex, race, or socioeconomic statusreceive their
acute, chronic, and preventive medical care services. recognizing
the importance of the Chronic Care Model as a contributor to the
PCMH 2006 ACP developed advanced medical home 2006 IBM and Patient
Centered Primary Care Collaborative to promote the medical home
concept
Slide 19
HISTORY OF THE PCMH 2007 Release of the Joint Principles of the
Patient- Centered Medical Home. American Academy of Family
Physicians American Academy of Pediatrics American College of
Physicians American Osteopathic Association Representing 333,000
physicians.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 20
HEALTH CARE ENDORSEMENTS American Academy of Hospice and
Palliative Medicine American Academy of Neurology American College
of Cardiology American College of Chest Physicians American College
of Occupational and Environmental Medicine American College of
Osteopathic Family Physicians American College of Osteopathic
Internists American Geriatrics Society American Medical Association
American Medical Directors Association American Society of
Addiction Medicine American Society of Clinical Oncology
Association of Professors of Medicine Association of Program
Directors in Internal Medicine Clerkship Directors in Internal
Medicine Infectious Diseases Society of America Society for
Adolescent Medicine Society of Critical Care Medicine
http://www.pcpcc.net/content/specialist-health-endorsements
Slide 21
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME 1.
Personal Physician 2. Physician Directed Medical Practice 3. Whole
Person Orientation 4. Care is Coordinated and/or Integrated 5.
Quality and Safety 6. Enhanced Access 7. Payment
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 22
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Personal
physician Each patient has an ongoing relationship with a personal
physician trained to provide first contact, continuous and
comprehensive care.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 23
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Physician
directed medical practice The personal physician leads a team of
individuals at the practice level who collectively take
responsibility for the ongoing care of patients.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 24
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Whole
person orientation The personal physician is responsible for
providing for all the patients health care needs or taking
responsibility for appropriately arranging care with other
qualified professionals. This includes care for all stages of life;
acute care; chronic care; preventive services; and end of life
care.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 25
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Care is
coordinated and/or integrated across all elements of the complex
health care system (e.g., subspecialty care, hospitals, home health
agencies, nursing homes) and the patients community (e.g., family,
public and private community-based services). Care is facilitated
by registries, information technology, health information exchange
and other means to assure that patients get the indicated care when
and where they need and want it in a culturally and linguistically
appropriate manner.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 26
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Quality
and safety are hallmarks of the medical home: Practices advocate
for their patients to support the attainment of optimal,
patient-centered outcomes that are defined by a care planning
process driven by a compassionate, robust partnership between
physicians, patients, and the patients family. Evidence-based
medicine and clinical decision-support tools guide decision making
Physicians in the practice accept accountability for continuous
quality improvement through voluntary engagement in performance
measurement and improvement. Patients actively participate in
decision-making and feedback is sought to ensure patients
expectations are being met Information technology is utilized
appropriately to support optimal patient care, performance
measurement, patient education, and enhanced communication
Practices go through a voluntary recognition process by an
appropriate non-governmental entity to demonstrate that they have
the capabilities to provide patient centered services consistent
with the medical home model. Patients and families participate in
quality improvement activities at the practice level.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 27
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Enhanced
access to care is available through systems such as open
scheduling, expanded hours and new options for communication
between patients, their personal physician, and practice staff.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 28
JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME Payment
appropriately recognizes the added value provided to patients who
have a patient-centered medical home. The payment structure should
be based on the following framework: It should reflect the value of
physician and non-physician staff patient-centered care management
work that falls outside of the face-to-face visit. It should pay
for services associated with coordination of care both within a
given practice and between consultants, ancillary providers, and
community resources. It should support adoption and use of health
information technology for quality improvement; It should support
provision of enhanced communication access such as secure e-mail
and telephone consultation; It should recognize the value of
physician work associated with remote monitoring of clinical data
using technology. It should allow for separate fee-for-service
payments for face-to-face visits. (Payments for care management
services that fall outside of the face-to-face visit, as described
above, should not result in a reduction in the payments for
face-to-face visits). It should recognize case mix differences in
the patient population being treated within the practice. It should
allow physicians to share in savings from reduced hospitalizations
associated with physician- guided care management in the office
setting. It should allow for additional payments for achieving
measurable and continuous quality improvements.
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
Slide 29
IHI TRIPLE AIM Work to improve site-specific care for
individuals should expand and thrive. In our view, however, the
United States will not achieve high-value health care unless
improvement initiatives pursue a broader system of linked goals. In
the aggregate, we call those goals the Triple Aim: improving the
individual experience of care; [better care] improving the health
of populations; [better health] and reducing the per capita costs
of care for populations. [lower cost] Donald M. Berwick, Thomas W.
Nolan and John Whittington The Triple Aim: Care, Health, And Cost.
Health Affairs, 27, no.3 (2008):759-769
Slide 30
PCMH OUTCOMES Better Health 2010 study showed improvement in
condition-specific outcomes (measures of the quality of care from
the Ambulatory Care Quality Alliance (ACQA) Starter Set), measures
of delivery of clinical preventive services and chronic disease
care. ACQA scores improved 8.3%-9.1% Chronic Care Scores improved
5.0%-5.2% Improved Prevention Scores (although not statistically
significant) Jan, C., Ferrer, R. et al., Patient Outcomes at 26
Months in the Patient-Centered Medical Home National Demonstration
Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.
Slide 31
PCMH OUTCOMES Better Health Air Force: 77% of diabetic patients
improved glycemic control MN: Health Partners: 129% increase in
optimal diabetes care; 48% in heart disease care NJ: BCBS of NJ: 8%
improvement in HgbA1c NC: Community Care of North Carolina: 21%
increase in asthma staging; 112% increase in influenza inoculations
Nielsen, M., Langner, B., et al. Benefits of Implementing the
Primary Care Patient-Centered Medical Home: A Review of Cost &
Quality Results, 2012. Patient-Centered Primary Care Collaborative.
2012.
Slide 32
PCMH OUTCOMES Better Health OH: Humana Queen City Physicians:
22% decrease in uncontrolled HTN OR: CareOregon Medicaid and Dual
Eligibles: 65% with controlled A1c vs 45% pre-PCMH PA: Geisinger
Health System Proven-Health Navigator PCMH Model: improved quality:
74% preventive Care, 22% Coronary Artery Care; 34.5 % Diabetes Care
Nielsen, M., Langner, B., et al. Benefits of Implementing the
Primary Care Patient-Centered Medical Home: A Review of Cost &
Quality Results, 2012. Patient-Centered Primary Care Collaborative.
2012.
Slide 33
PCMH OUTCOMES Better Health PA: Independence Blue Cross
Pennsylvania Chronic Care Initiative: in Diabetics: 49&
improvement in A1c; 25% increase in BP control; 27% increase in
cholesterol control TX:WellMed, Inc: LDL control from 51% to 95% in
heart disease patients; mammography from 19% to 40%; colon cancer
screening from 11% to 50% Nielsen, M., Langner, B., et al. Benefits
of Implementing the Primary Care Patient-Centered Medical Home: A
Review of Cost & Quality Results, 2012. Patient-Centered
Primary Care Collaborative. 2012.
Slide 34
PCMH OUTCOMES Better Care 2010 study showed no improvement in
patient related outcomes including ratings of the 4 pillars of
primary care (easy access to first-contact care, comprehensive
care, coordination of care, and personal relationship over time),
global practice experience, patient empowerment, and self-rated
health status. Jan, C., Ferrer, R. et al., Patient Outcomes at 26
Months in the Patient-Centered Medical Home National Demonstration
Project. Ann Fam Med 2010;8(Suppl 1):s57-s67.
Slide 35
PCMH OUTCOMES Better Care CO: Colorado Medicaid and SCHIP:
Increased well-care visits 54%->73% FL: Capital Health Plan:
250% increase in primary care visits MA: Pediatric Alliance for
Coordinated Care: 60.9% reported increased ease to communicate with
MD, 61.4% reported it was easier to get early medical care MI: BCBS
of Michigan: 60% better access to care (25% in non- participating
sites) Nielsen, M., Langner, B., et al. Benefits of Implementing
the Primary Care Patient-Centered Medical Home: A Review of Cost
& Quality Results, 2012. Patient-Centered Primary Care
Collaborative. 2012.
Slide 36
PCMH OUTCOMES Better Care MN: Healthpartners: reduced
appointment wait time by 350% (26 days to 1 day) ND: BCBS of North
Dakota-MediQHome Quality Program: 24% reduction in ED visits,
30%reduction in ED visits in chronic disease patients NY: Capital
District Physicians Health Plan: 24% lower hospital admissions OK:
Oklahoma Medicaid: 8% increase in always getting treatment quickly
PA: PinnacleHealth: 0% 30-day readmission rate vs 10-20% for non-
PCMH Nielsen, M., Langner, B., et al. Benefits of Implementing the
Primary Care Patient-Centered Medical Home: A Review of Cost &
Quality Results, 2012. Patient-Centered Primary Care Collaborative.
2012.
Slide 37
PCMH OUTCOMES Better Care Veterans Health Administration and VA
Midwest Healthcare Network: 8% reduction urgent care visits, 4%
reduction in acute admission rates, 27% reduction in admissions for
chronic disease patients WA: Regence Blue Shield (Intensive
Outpatient Care Program with Boeing) 2012: 65% reduced patient
reported missed workdays WA: Group Health of Washington: 83% of
patient calls resolved on first (vs. 0% pre-PCMH) Nielsen, M.,
Langner, B., et al. Benefits of Implementing the Primary Care
Patient-Centered Medical Home: A Review of Cost & Quality
Results, 2012. Patient-Centered Primary Care Collaborative.
2012.
Slide 38
PCMH OUTCOMES Lower Costs CA: BCBS of California ACO Pilot:
%15.5 million overall health care cost savings CO: Colorado
Medicaid and SCHIP: $215 lower PMPY Idaho: BCBS of Idaho Health
Service: $1 million reduction in single year claims MD: CareFirst
BCBS: 4.2% reduction in expected health care costs for patients in
60% of practices participating for 6+ months.; $40 million savings
in 2011. Nielsen, M., Langner, B., et al. Benefits of Implementing
the Primary Care Patient-Centered Medical Home: A Review of Cost
& Quality Results, 2012. Patient-Centered Primary Care
Collaborative. 2012.
Slide 39
PCMH OUTCOMES Lower Costs NC: Community Care of North Carolina:
$1.145 billion savings between 2006-2010; 11% lower pharmacy costs
OR: CareOregon Medicaid and Dual Eligibles: 9% lower PMPM costs SC:
BCBS of South Carolina: 6.5% lower total PMPM medical and pharmacy
costs TX: BCBS of Texas: $1.2 million health care costs savings
Nielsen, M., Langner, B., et al. Benefits of Implementing the
Primary Care Patient-Centered Medical Home: A Review of Cost &
Quality Results, 2012. Patient-Centered Primary Care Collaborative.
2012.
Slide 40
PCMH OUTCOMES Provider Satisfaction WA: Group Health of
Washington: Less emotional exhaustion (10% vs 30% in control group)
Nielsen, M., Langner, B., et al. Benefits of Implementing the
Primary Care Patient-Centered Medical Home: A Review of Cost &
Quality Results, 2012. Patient-Centered Primary Care Collaborative.
2012.
Slide 41
OBJECTIVES By the end of this session the learner will be able
to: Discuss the need for change in the healthcare system of the US.
Describe the seven principles of the patient-centered medical home
Describe some of the proven benefits of the patient-centered
medical home Discuss the variety of locations, collaborative
partners, clinic types and health care settings that have
successfully used the patient centered medical home
Slide 42
BIBLIOGRAPHY Donald M. Berwick, Thomas W. Nolan and John
Whittington The Triple Aim: Care, Health, And Cost. Health Affairs,
27, no.3 (2008):759-769 The World Health Report 2000 Health
systems: Improving performance Starfield B. Is US Health Really the
Best in the World?. JAMA. 2000;284(4):483-485. To Err is Human:
Building a Safer Health System, Institute of Medicine. Sept 1999.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
program: 2012 Clinician & Group Survey Results
http://www.factcheck.org/2011/07/fiscal-factcheck/
http://www.factcheck.org/2011/07/fiscal-factcheck/
http://www.marketwatch.com/health-care/reform/snapshot
http://www.marketwatch.com/health-care/reform/snapshot K. Davis, C.
Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum.
Slowing the Growth of U.S. Health Care Expenditures: What Are the
Options?, The Commonwealth Fund, January 2007
http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
N England Journal of Medicine 2001;344:2021-25]:
Slide 43
BIBLIOGRAPHY
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
http://www.pcpcc.net/content/specialist-health-endorsements
http://www.pcpcc.net/content/specialist-health-endorsements
Nielsen, M., Langner, B., et al. Benefits of Implementing the
Primary Care Patient-Centered Medical Home: A Review of Cost &
Quality Results, 2012. Patient-Centered Primary Care Collaborative.
2012. The Patient Centered Medical Home: History, Seven Core
Features, Evidence and Transformational Change. Robert Graham
Center for Policy Studies in Family Medicine and Primary Care.
November 2007. Starfield, B., Shi, L., and Macinko, J.,
Contribution of Primary Care to Health Systems and Health. The
Milbank Quarterly, Vol. 83, No. 3, 2005 (pp.457-502). Jan, C.,
Ferrer, R. et al., Patient Outcomes at 26 Months in the
Patient-Centered Medical Home National Demonstration Project. Ann
Fam Med 2010;8(Suppl 1):s57-s67.
Slide 44
QUESTIONS? The slides from this presentation and some of the
source material are available at the Tulane Department of Family
and Community Medicine.
http://tulane.edu/som/departments/fammed/seminars.cfm