AHRQ and the Medical Home: Building a Blueprint (Text Version)

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Slide 1

AHRQ and the Medical Home: Building a Blueprint

David Meyers, MD
Director, AHRQ Center for Primary Care

AHRQ Annual Conference
September, 2010

Slide 2

Disclosures

• The speaker has no financial or other conflicts of interest to report.

Slide 3

Disclosures

• The speaker has no financial or other conflicts of interest to report.
• (After all, I'm a bureaucrat)

Slide 4

Bureaucrat

• bu-reau-crat
  1. an official of a bureaucracy.
  2. an official who works by fixed routine without exercising intelligent judgment.
• Or in my son's words...
  • I go to a lot of meetings and spend my day reading and writing E-mail.

Slide 5

Session Overview

• Introductions and Welcome (5 minutes)
• An Update on AHRQ's Activities in Support of the PCMH (15 min)
• Perspective: Research Needs (10 min)
  • Debbie Peikes
  • Senior Researcher, MPR
• Perspective: Implementer Needs (10 min)
  • Michael Barr, Vice President, ACP
• Audience Response (40 minutes)
  • Where should AHRQ focus future activities in support of the PCMH?
• Wrap-up (5 minutes)

Slide 6

Goals

1. Participants will leave with an understanding of AHRQ's activities in support of the primary care PCMH.
   1. Participants will see how feedback from their colleagues in 2009 has been incorporated into AHRQ's activities.
2. AHRQ will leave with a fuller understanding of the needs of its stakeholders.
   1. Researchers
   2. Implementers
   3. Policy-makers
   4. American public

Slide 7

Image: The AHRQ logo is shown.

Slide 8

AHRQ Mission Statement

To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

Slide 9

What AHRQ does

• Generates New Knowledge

Slide 10

The Medical Home

• AHRQ believes that the primary care medical home, also referred to as the patient centered medical home (PCMH), advanced primary care, and the healthcare home, is a promising model for transforming the organization and delivery of primary care.
• Synthesize evidence.
• Supports implementation.

Slide 11

A home for the PCMH

• Center for Primary Care, Prevention, and Clinical Partnerships
  • Primary Care
    • PBRNs
  • Health IT
  • Prevention and Care Management
  • Mental Health / Primary Care Integration

Slide 12

Primary Care

AHRQ recognizes that revitalizing the Nation's primary care system is foundational to achieving high-quality, accessible, efficient health care for all Americans.

Slide 13

The Medical Home

• A medical home is not simply a place but a model of primary care that delivers care that is:
  • Patient-Centered
  • Comprehensive
  • Coordinated
  • Accessible, and
  • Continuously improved through a systems-based approach to quality and safety

Slide 14

The Medical Home

• A medical home is not simply a place but a model of primary care that delivers the care that is:
  • Patient-Centered
  • Comprehensive
  • Coordinated
  • Accessible, and
  • Continuously improved through a systems-based approach to quality and safety
• AHRQ believes that Health IT, workforce development, and payment reform are critical to achieving the potential of the medical home.

Slide 15

AHRQ's Definition of the Medical Home

http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_

Slide 16

AHRQ and the Joint Principles Closely Aligned

AHRQ

• Patient-Centered
• Comprehensive
  • Team-based care
• Coordinated
• Accessible
• Quality and safety
• Health IT
• Workforce development
• Payment reform

AAFP, AAP, ACP, AOA

• Personal physician
• Physician directed practice
• Whole person orientation
• Care Coordination
  • Health IT
• Quality and safety
• Enhanced access
• Payment

Slide 17

AHRQ PCMH Research

• Retrospective Evaluations:
  • Health Partners (Minnesota)
  • WellMed (Texas)
• Mixed Methods Evaluations:
  • Transforming Primary Care Practice
    • 14 2-year awards
    • $600K per study
    • Awarded summer 2010
• Establishing a Research Agenda:
  • Co-funded with CWMF and ABIMF
  • Collaboration of SGIM, STFM, APA
  • Results published June 2010 in JGIM

Slide 18

Measurement

• Developing measures of care coordination in primary care:
  • Care Coordination Measure Atlas
    • Collaboration of Battelle and Stanford
    • Released this week
  • Phase II of measure development 2010-11

Slide 19

Measurement

• Developing measures of care coordination in primary care.
• Planning for development of measure of "team-ness":
  • Multi-partner collaboration.
  • Kick-off meeting held earlier this month.
• Measurement
  • Developing measures of care coordination in primary care.
  • Developing a PCMH version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Planning for development of measure of "team-ness"
    • Expected in 2011

Slide 20

Synthesis

• Foundational White Papers:
  • Necessary but Not Sufficient: The HITECH Act's Potential to Build Medical Homes
  • Engaging Patients and Families in the Medical Home
  • Integrating Mental Health into the Medical Home
  • Developed in collaboration with Mathematica Policy Research and National Commission on Quality Assurance

Slide 21

Synthesis

• Foundational White Papers:
  • Necessary but Not Sufficient: The HITECH Act's Potential to Build Medical Homes
  • Engaging Patients and Families in the Medical Home
  • Integrating Mental Health into the Medical Home
  • Address Policy and Research Issues

Slide 22

Necessary but Not Sufficient: The HITECH Act's Potential to Build Medical Homes

• While the meaningful use of Electronic Health Records (EHRs) helps support some aspects of the PCMH model, policy options available in HITECH and in broader health reform legislation could ensure EHRs are implemented in a way that will support primary care transformation.

Slide 23

Necessary but Not Sufficient: The HITECH Act's Potential to Build Medical Homes

• Policy options include:
  1. Adding explicit functionalities that directly support the PCMH model to the recently released EHR certification standards and criteria.
  2. Adding meaningful use requirements that support the PCMH model for stages 2 and 3 of the EHR Incentive Program.
  3. Funding the provision of technical assistance to primary care practices on PCMH transformation alongside the planned assistance on health IT adoption through Regional Extension Centers (RECs) or through a Primary Care Extension Service.

Slide 24

Engaging Patients and Families in the Medical Home

How can policymakers ensure that the PCMH is responsive to and reflective of the goals, preferences, and needs of patients?

• By promoting the involvement of patients and families in the medical home at three levels:
  • In their own care,
  • In practice-level quality improvement, and
  • In policy and research

Slide 25

Engaging Patients and Families in the Medical Home

Policy options include:

• Requiring patient involvement to qualify a practice as a medical home.
• Using financial incentives to reward practices for involving patients and families.
• Supporting practices with technical assistance and tools.
• Ensuring Health IT is patient-focused.
• Incorporating patient input in the design, implementation, and evaluation of medical home pilot projects.
• Conducting additional research.

Slide 26

Integrating Mental Health into the Medical Home

• Normalize MH in mainstream medical practice—truly adopt a whole person approach to care.
• Integrate reimbursement for the time and resources needed to provide MH treatment in the PCMH.
• Develop performance measures to encourage adoption of integration while providing a source for ongoing feedback and improvement opportunities.

Slide 27

Two Additional Reports

• Building Value: The Role of PCMHs and ACOs in Care Coordination
• Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care

Slide 28

Synthesis

• Database of published literature on the medical home:
  • Over 500 citations.
  • Searchable by PCMH domain, policy relevance, and outcomes.
  • Includes a section on foundational documents and articles.

Slide 29

Implementation

Slide 30

Synthesis

• Planned white papers for 2011:
  • Analysis of PCMH outcomes.
  • Exploration of PCMH within the larger health care system.
  • With potential for additional topics.
• Upcoming series of briefs on the status of primary care in the US:
  • Includes new analysis of the primary care workforce.
• Toolkit on integrating the CCM in safety net setting:
  • Visit: http://www.ahrq.gov/populations/businessstrategies/
  • Companion toolkit on utilizing practice coaching:
    • Visit: http://www.ahrq.gov/populations/businessstrategies/coachmanl.htm
  • Currently conducting field evaluation
• National learning collaborative around the use of practice facilitators and practice coaching:
  • Launching fall 2010

Slide 31

Implementation

• Building a PCMH Information Model:
  • Describe the PCMH in terms of the information flows and interactions between and among patients/consumers and other PCMH stakeholders.
  • Develop new 'functional use cases'.
  • Examine current standards and existing 'technical use cases' in relation to the PCMH.
  • Identify gaps.
  • Contract awarded to Westat.
  • Began Summer 2010.

Slide 32

Opportunities

• 2010 Affordable Care Act:
  • Section 3502: Establishing community health teams to support the patient-centered medical home.
  • Section 5405: Primary Care Extension Program.

Both sections authorized without the appropriation of funds

Slide 33

Putting it All Together

• Research
• Measurement
• Evidence Synthesis
• Evidence-informed Policy Options
• Implementation

Slide 34

Dissemination

Screen shot of PCMH.AHRQ.Gov

Slide 35

PCMH.AHRQ.Gov

• Targeted towards meeting the needs of Policy Makers and Researchers.
• Includes:
  • AHRQ definition of the medical home.
  • Searchable article database.
  • Foundational white papers
    • Health IT
    • Patient and Family Engagement
    • Mental Health Integration
    • And additional reports

Slide 36

PCMH.AHRQ.Gov

• Targeted towards meeting the needs of Policy Makers and Researchers.
• Includes:
  • AHRQ definition of the medical home.
  • Searchable article database.
  • Foundational white papers.
• Will continue to grow and expand.

Slide 37

PCMH.AHRQ.Gov

• Targeted towards meeting the needs of Policy Makers and Researchers.
• Includes:
  • AHRQ definition of the medical home.
  • Searchable article database.
  • Foundational white papers.
• Will continue to grow and expand.

Please visit and help us spread the word

Slide 38

Federal Collaboration

• AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care

Slide 39

Federal Collaboration

• AHRQ heard from federal partners as well as external stakeholders the need to coordinate federal activities around the PCMH and primary care.
• In response, AHRQ convened a Federal Collaborative on the PCMH:
  • Share information so that participants have a common understanding of PCMH.
  • Foster collaborations and share expertise.

Slide 40

Thank You

• One minute for clarifying questions.
• Research Needs and the Needs of Researchers
  • Remarks from Debbie Peikes, Ph.D.
    • Senior Researcher at Mathematica Policy Research
    • Visiting Lecturer at Princeton University

Slide 41

The Patient-Centered Medical Home: Research Needs and the Needs of Researchers

September 27, 2010
AHRQ Annual Conference
Bethesda, MD
Debbie Peikes, Ph.D.

Mathematica Policy Research, Inc.

Slide 42

We Need Good Evaluations

• Payers/insurers: Will the PCMH reduce costs enough to cover the payments to providers and in-kind supports?
• Practices: Transformation requires staffing, IT changes, time, and $. Will these translate into more satisfaction, $?
• Patients: Will experience and outcomes improve? Will premiums fall?
• Vendors: Will this movement exist in 5 years?

Slide 43

The PCMH Model is Promising... but Risky

Risks:

• Model isn't actually implemented fully.
• Model is implemented, but does not work.
  • Increases costs.
  • Decreases satisfaction of patients.
  • Decreases provider satisfaction.
  • Decreases quality.
• Simply proceeding without evidence may divert resources from other primary care transformations that would work.

Slide 44

What Can an Evaluation Deliver?

• Document whether the PCMH model was implemented.
• Identify barriers and facilitators to being a medical home.
• Assess effectiveness to justify investment.
• Measure performance to reward providers differentially.
• Guide replication of successful features.

Slide 45

How Do Practices Evolve into Medical Homes?

• Efforts needed to reach MH criteria (time, internal and external resources, $).
• Limits, potential of health IT.
• Ease of changing staffing and workflows.
• Resources required from outside the practice.
• Best practices and models:
  • For patient outreach, recruitment, and engagement.
  • For coordination.
  • For chronic care, etc.

Slide 46

What Is the Impact of the PCMH?

• Disease-specific and population-based quality of care measures:
  • Process: Evidence-based care (e.g., foot exams for patients with diabetes).
  • Outcomes: Ambulatory-care sensitive complications.
  • Coordination of care (harder to measure).
  • Patient experience:
• Provider experience:
  • If providers are worse off, they won't want to do this.
• Service use and cost
  • If this isn't cost neutral or cheaper, payers won't play.

Slide 47

Current Research Evidence is Weak

• Well designed studies are not testing the full medical home (e.g., Guided Care, GRACE), or do so in a closed system (Group Health), or don't have access to cost data (NDP).
• Many studies are poorly designed, or do not report methods (e.g., North Carolina).
• Many planned studies are too short, have not represented the counterfactual, do not address clustering, and are underpowered.

Slide 48

Research Needs-2

Slide 49

Research Needs

1. Standardized measures of different medical home models to test variants.
2. Fair comparison groups-similar before the intervention:
   • At the practice level.
   • At the patient level.
   • Consider random assignment, staggered rollouts.
3. Information on best claims-based approaches to attribute patients to their practices.
4. Adequate follow-up:
   • Need time to allow transformation to happen.
   • Most evaluations are using only 1.5-2 years.
5. Statistical techniques that account for clustering at the practice level:
   • Not doing so will give false positives.
6. Large sample sizes:
   • We may erroneously find no effect because practices don't have enough time to change or there isn't enough sample to detect change.
   • Costs vary so much it is difficult to separate intervention effects from random noise (this affects P4P too!).
7. Data repositories and guidelines for cross-walking all payer claims data.
8. Well defined intermediate and final outcome measures that are comparable across studies.

Slide 50

Your Thoughts?

Dpeikes@mathematica-mpr.com

Slide 51

Feedback from the Front Lines

• Remarks from Michael Barr

Slide 52

Feedback from the Front Lines

AHRQ Annual Meeting
September 2010

Michael S. Barr, MD, MBA, FACP
Senior Vice President
Division of Medical Practice, Professionalism & Quality
202-261-4531
mbarr@acponline.org

Slide 53

Disclosure of Conflicts of Interest:

Grant funding from Pfizer and UnitedHealthGroup to support program development (ACP Medical Home Builder)

Quality improvement programs sponsored by pharmaceutical companies as part of ACPNet & ACP Closing the Gap

Slide 54

Change

Slide 55

"I put a dollar in a change machine. Nothing changed."
- George Carlin

Next to the quote is Image: George Carlin.

Slide 56

Anecdotal Reactions

Slide 57

What Some Physicians Hear...

Patient-Centered Medical Home
Health Care Home
Person-Centered Health Care Home
Meaningful Use
Certified EHR Technology
Complete EHRs
EHR Modules
Accountable Care Organizations
Affordable Care Act (PPACA, ACA)
Maintenance of Certification
Physician Quality Reporting Initiative—PQRI
HITECH
E-prescribing Incentive Program

Slide 58

What Some Physicians See...

Image: A drawing by M.C. Escher.

Slide 59

What Some Physicians Say...

• Honestly, I have given up on all my professional organizations—they simply cannot or will not understand the point of view of the solo practitioner.
• Haven't we given up enough of our autonomy? Aren't enough non-physicians in control of our destiny as it is?
• I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession.
• ...the complex requirements of "meaningful use" mainly serve the EHR companies (who, not surprisingly, had a hand in developing the rule).

Slide 60

How Some Physicians Feel.

Image: A pyramid. The levels are follows:

Top level: Service
Level 2: Technology
Level 3: Workflow/Logistics
Level 4: Organization/Infrastructure
Level 5: Personnel/Training/Competency

Slide 61

Physicians Need...

Clarity about...

• Short/long-term goals
• Implications of public policy

Coaching for...

• Team-based/patient-oriented practice
• Business/QI/Health IT implementation

Confidence that...

• Support will not fade
• Unintended consequences will not prevail

Slide 62

Listening Session

• We invite members of the audience to share their observations and recommendations with AHRQ.
  • Our primary goal is to learn from you what you see as the role for AHRQ moving forward.