Medical Home: Primary Care for the 21 st Century Is This the Path to Quality and Value in Health Care?

Louisiana Health Care Quality Forum May 23, 2008 Richard C. Antonelli, MD, MS, FAAP Assoc Prof Pediatrics, Univ Conn SOM Chief of General Pediatrics Connecticut Children’s Medical Center AAP National Center for Medical Home Initiatives Project Advisory Committee

Every System is Perfectly Designed to Get the Results it Gets

– Institute for Healthcare Improvement – National Initiative for Children’s Healthcare Quality

Definition of Medical Home

• Care that is: – Accessible – Family-centered – Comprehensive – Continuous – Coordinated – Compassionate – Culturally-effective

Definition of Medical Home

• And for which the primary care provider shares responsibility with the family.

AAP/ AAFP/ NAPNAP/ ACP

Functional Definition of Medical Home

• Partnership between family and providers • Commitment to continuous quality assessment and improvement • Single point of entry to a “system” of care that facilitates access to medical and non medical resources

Joint Principles of the PCMH AAP, AAFP, ACP, AOA March 2007 • Whole person orientation • Personal physician • Physician directed medical practice • Care is coordinated and/or integrated • Quality and safety • Enhanced access to care • Payment to support the PC-MH

Issues

• Can Primary Care Survive?

– Capacity of current workforce – Attracting new providers to workforce • What About Quality and Value?

• Do We Need Medical Home?

– Highest quality with least disparity to access occurs when Medical Home available

What About Disparity?

Figure 8. Across Income Levels, African Americans Are More Likely to Have Health Problems, Even After Adjusting for Age

Percent of adults ages 19–64 with health problems* 100 White African American 75 63 51 50 50 38 39 28 25 32 Hispanic 45 23 0 Total Under 200% poverty 200% poverty or more

* Defined as having any chronic condition or disability.

Note: Percentages are age-adjusted.

Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

Lacking Health Insurance for Any Period Threatens Young Adults’ Access to Care, 2005 Percent of adults ages 19–29 reporting the following problems in the past year because of cost: Insured all year Insured now, time uninsured in past year Uninsured now 80 54 57 42 45 40 32 38 31 37 28 35 31 17 12 11 18 0 Did not fill a prescription Did not see specialist when needed Skipped medical test, treatment, or follow-up Had medical problem, did not see doctor or clinic Any of the four access problems

Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

The Result of Delayed Access?

• More Expensive Care Rendered in Emergency Departments • In case of Mental Health, services “rendered” in criminal justice system

Figure ES-1. Nearly Half of Hispanics and One of Four African Americans Were Uninsured for All or Part of 2006 Percent of adults 18–64 75 50 25 0 Uninsured now 26 9 17 Total 21 8 13 White Insured now, time uninsured in past year 49* 14 28 11 17 African American 35 Hispanic 18 8 10 Asian American

* Compared with whites, differences remain statistically significant after adjusting for income.

Source: Commonwealth Fund 2006 Health Care Quality Survey.

Figure ES-3. Uninsured Are Least Likely to Have a Medical Home and Many Do Not Have a Regular Source of Care Percent of adults 18 – 64 Medical home Regular source of care, not a medical home No regular source of care/ER 100 75 50 25 0 27 54 30 61 34 54 20 Total 9 Insured all year, income at or above 200% FPL 12 Insured all year, income below 200% FPL

Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time.

* Compared with insured with income at or above 200% FPL, differences are statistically significant.

Source: Commonwealth Fund 2006 Health Care Quality Survey.

16* 39 45 Any time uninsured

Figure ES-4. Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it 100 75 74 Medical home Regular source of care, not a medical home No regular source of care/ER 74 76 74 50 52 38 53 44 52 31 25 50 34 0 Total White African American

Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time.

Source: Commonwealth Fund 2006 Health Care Quality Survey.

Hispanic

CSHCN receive coordinated, ongoing, comprehensive care within a medical home 2005-2006

Families of CSHCN will be partners in decision-making and are satisfied with the services they receive 2005-2006

Families of CSHCN will have adequate private and public insurance to pay for the services they need 2005-2006

% of CSHCN whose family members cut back and/or stop working because of child's health needs 2005-2006

What Is Important About Primary Care?

Primary Care Score vs. Health Care Expenditures, 1997 2 UK UK DK DK 1.5

SP SP 1 FIN FIN NTH NTH NZ SWE SWE AUS AUS JAP JAP CAN CAN 0.5

BEL BEL FR FR GER GER US US 0 1000 1500 2000 2500 3000 3500

Per Capita Health Care Expenditures

4000 Starfield 06/02

While access to insurance is an important and necessary determinant for having a Medical Home, it is not sufficient to predict quality of care or outcomes.

Is Medical Home Enough?

• Transforming American Healthcare from a “Sector” to a “System” Requires Broad based Re-design: – Financing – Quality measurement – Regulatory support – State and Federal policy support • Infrastructure is Medical Home

Priority Areas for National Action: Transforming Health Care Quality

• Priorities Relating to Children and Youth – Care Coordination- across paradigms of care – Self-management/ health literacy – CSHCN – Immunizations – Depression – Medication Management Institute of Medicine

Chronic Care Model (Wagner, et al) Community Resources and Policies Health System Health Care Organization (Medical Home) Care Partnership Support Delivery System Design Decision Support Clinical Information Systems Supportive, Integrated Community Informed, Activated Patient/Family Prepared, Proactive Practice Team Family centered Timely & efficient Evidence-based & safe Coordinated and Equitable Functional and Clinical Outcomes

What is Care Coordination?

A process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health.

AAP 2005

Care Coordination- ACP

• Ensuring communication among specialists and PCP and families • Tracking if referrals happen • System to prevent errors among multiple providers • Tracking Test Results

What Is the Result of CC in a Pediatric Medical Home?

Outcome Prevented

– Aggregate Data Antonelli and Antonelli, Pediatrics 2004 The CCMT allows only one outcome prevented per encounter.

32% of total 3855 CC encounters prevented something.

Of the 1232 CC Encounters where prevention was noted as an outcome: Outcome Prevented Visit to Pediatric Office / Clinic Emergency Department Visit Subspecialist Visit Hospitalization Lab / X-Ray Specialized Therapies # CC Encounters Percentage 714 323 124 47 16 8

62% of RN CC Encounters prevented something. 33% of MD CC Encounters prevented something

. 58% 26% 10% 4% 1% 1%

RNs are responsible for coding 81% of the Emergency Department preventions and 63% of the sick office visit preventions

.

What Can Be Measured re: CC?

• Adult Medical Home – Screening rates for disease and risk factors – Screening for secondary disabilities – Presence of registry and its utilization – Development of Care Plans (these have CPT codes already) – Mechanism for linkage from practice-based CC to community-based CM – Training opportunities for CC’ers – ED and in-patient utilization for patients with chronic conditions

What Can Be Measured re: CC?

• Pediatric Medical Home – Parent/ youth partners in QI at practice level – Developmental and behavioral screening – Screening for secondary disabilities (much less prevalent than adult practice) – Presence of registry and its utilization – Development and deployment of Care Plans (these have CPT codes already) – Mechanism for linkage from practice-based CC to community based CM – Training opportunities for CC’ers – ED and in-patient utilization for patients with chronic conditions

Stakeholders

• Families • Employers (Leapfrog Group, National Quality Forum) • Providers • Community-Based Organizations • Payers: Medicaid and Commercial (PCPCC) • State and Federal Agencies • Legislators

PCMH-PPC: NCQA, AAFP, ACP, AAP and AOA Medical Home Recognition Criteria Linked to Reimbursement

National Noteworthy Models of Medical Home and Care Coordination

• Minnesota Medicaid Transformation • North Carolina • PACE: case management/ CC for adults with chronic conditions

Useful Websites

• http:// www.medicalhomeinfo.org

: American Academy of Pediatrics hosted site that provides many useful tools and resources for families and providers • http:// www.medicalhomeimprovement.org

: tools for assessing and improving quality of care delivery, including the Medical Home Index, and Medical Home Family Index

References

• McPherson, M., Arango, P., Fox, H., et al. (1998). A new definition of children with special health care needs.

Pediatrics

,

102

,137–140 • U.S. Department of Health and Human Services. www.hhs.gov/newfreedom , accessed April 26, 2005 • Committee on Children with Disabilities, American Academy of Pediatrics. (2005). Care coordination policy statement

References (cont)

• Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21 st century • Committee on Identifying Priority Areas for Quality Improvement, Institute of Medicine. (2003). Priority areas for national action: Transforming health care quality. Adams, K. and Corrigan, J. Editors.

• Providing a Medical Home:The Cost of Care Coordination Services in a Community-Based, General Pediatric Practice,

Pediatrics, Supplement

, May, 2004, Antonelli, R. and Antonelli, D.