The building blocks of high- performing primary care

Loading...

The building blocks of highperforming primary care Tom Bodenheimer MD Center for Excellence in Primary Care, UCSF

Optimal healthcare system design

2

3° Care



Care

2° 2° Care Care 1° Care1° Care 3

Our healthcare system

4

Adult primary care crisis • Plummeting numbers of new practitioners entering primary care • Declining access to primary care • Practitioner burn-out • Unsatisfactory quality • The primary care medical home is falling off the cliff

Residency Match, 2010 % of graduating US medical students choosing specialties

2010 NRMP Main Residency Match data

Percent change relative to 2001

50

Adult Care: Projected Generalist Supply vs Pop Growth+Aging

45 40

Demand:adult pop’n growth/aging

35 30 25

Gap: 40,000

20 15 10

Supply, Family Med, Gen’l Internal Med

5 0 2000

2005

2010

2015

Colwill et al., Health Affairs, 2008:w232-241

2020

NP/PAs to the rescue? • New graduates each year – Nurse practitioners: 8000 – Physician assistants: 4500 • % going into primary care – NPs: 65% – PAs: 32% • Adding new GIM, FamMed, NPs, and PAs entering primary care each year, the primary care practitioner to population ratio will fall by 9% from 2005 to 2020. Colwill et al, Health Affairs Web Exclusive, April 29, 2008; Bodenheimer et al, Health Affairs 2009;28:64.

Why do we need to transform primary care? • Stressful worklife • Survey of 422 general internists and family physicians 2001-2005 – 48%: work pace is chaotic – 78%: little control over the work – 27%: definitely burning out – 30%: likely to leave the practice within 2 years Linzer et al. Annals of Internal Medicine 2009;151:28-36

Why do we need to transform primary care? • 73% of adults surveyed reported difficulty getting a prompt appointment, getting phone advice, or getting care nights/weekends without going to the ER. Public views on of US health system organization, Commonwealth Fund, 2008

• 50% of people with hypertension, 80% of people with high cholesterol, 43% of people with diabetes are poorly controlled. Egan et al. JAMA 2010; 303(20):2043-2050, Ford, Internat’l J Cardiol 2010;140:226, Cheung et al. Am J Med 2009;122:443 10

Why do we need to transform primary care? • 23 seconds: Average time before patients were interrupted when making initial statement of their problem to their primary care physician. Marvel et al. JAMA 1999;281:283

• 50% of patients leave the office visit without understanding what their physician said. Schillinger et al. Arch Intern Med 2003;163:83 11

The problem: panel sizes too large for primary care physicians to manage alone • A primary care physician with an panel of 2500 average patients will spend 7.4 hours per day doing recommended preventive care. Yarnall et al. Am J Public Health 2003;93:635

• A primary care physician with an panel of 2500 average patients will spend 10.6 hours per day doing recommended chronic care. Ostbye et al. Annals of Fam Med 2005;3:209

Average panel size in the US is 2300 patients Alexander et al. J Gen Intern Med 2005; 20:1079-83. 12

Primary care provisions of the Affordable Care Act (ACA) • 2011: 10% increase in primary care Medicare fees • 2013/4: Medicaid primary care fees must be equal to Medicare fees; federal government pays, not states • 2010: HHS will reduce specialty payment and increase primary care payment for Medicare • 2011: Medical home pilots tested by CMS innovation center • CMS innovation center will test payment reforms

Transforming practice Group Health Factoria Clinic • • • • • • • •

Panel size reduced from 2300 to 1800 Visit length increased from 20 - 30 minutes 1/3 face-to-face, 1/3 phone, 1/3 email Physician burnout dropped from 25% - 14% Burnout in control clinics grew from 28% - 35% Quality measures improved Patient experience measures improved $1 million investment recovered in one year by reduced ED visits and hospital admissions • After 21 months, savings of $10.30 pmpm compared to control clinics Reid et al. Am J Managed Care 2009;15(9):e71-87. Reid et al. Health Affairs May 2010

Building blocks of high-performing primary care 1. Shared mission (vision) and concrete goals 2. Data driven improvement

3. Empanelment and panel size management 4. Team-based care 5. Population-based management 6. Continuity of care 7. Prompt access to care 8. Template of the future: escape from 15-minute visit 9. Coordination of care 10. Conscious and trained leadership

Empanelment and panel size management • Empanelment = linking patients with a primary care clinician/team • Advantages: – Patient and clinician/team know each other – Allows clinic to measure continuity of care (does patient always see his/her clinician/team?) – Allows calculation of panel size – Provides denominator for quality measures

• Proper panel size crucial for providing access • Empanelment Guide www.qhmedicalhome.org/safetynet/Empanelment.cfm

Building blocks of high-performing primary care 1.

Shared mission (vision) and concrete goals

2. Data driven improvement 3. Empanelment and panel size management

4. Team-based care 5. Population-based management 6. Continuity of care 7. Prompt access to care 8. Template of the future: escape from 15-minute visit 9. Coordination of care 10. Conscious and trained leadership

Elements of team-based care • Culture shift • Stable teamlets • Colocation • Defined workflows and roles – workflow mapping • Training, skills checks, and cross training • Ground rules • Communication – healthy huddles, terrific team meetings and minute-to-minute talk • Standing orders/protocols

Culture shift: I to We, individual care to population care • Instead of: “what can I do to maximize the care of the 30 patients on my schedule today?”

Monday

Patients

8:00AM

Ms. Ngo

8:15AM

Mr. Barnes

8:30AM

Ms. Reilly

8:45AM

Mr. Padilla

• The future: “what can we do to maximize the care of the 1500 patients in our panel?” 19

Stable teamlets Patient panel Clinician/MA teamlet

Patient panel Clinician/MA teamlet

Patient panel Clinician/MA teamlet

RN, social worker, pharmacist, health educator, nutritionist, care manager, panel manager

1 team, 3 teamlets

Co-location: Clinica Family Health Services

Ground rules • Team members treat each other with respect • When someone makes a mistake, he/she is given helpful feedback on how to improve • Everyone is expected at AM huddles on time • Team meetings have an agenda, facilitator, note taker • MDs should not dominate meetings; everyone should be active participants in meetings • Are decisions made by by consensus, by leader, by vote? • What are the consequences of tardiness, excessive absences? • What is the mechanism to resolve conflicts?

Standing orders for RNs or MAs to do diabetes refills without involving the clinician Appointment HbA1c = 7.5 Normal creatinine last 6 months or below and potassium in last 6 months

How to refill

Yes

Yes

Yes

3 month supply + 1 refill

Yes

Yes or No

No

1 month supply + order labs, give appt, no refill

Yes

No

Yes

1 month supply + give appt, no refill

No

Yes

Yes

3 month supply + give appt, no refill

No

No

Yes or No

1 month supply + give appt, no refill

Building blocks of high-performing primary care 1. Shared mission (vision) and concrete goals 2. Data driven improvement 3. Empanelment and panel size management 4. Team-based care 5. Population-based management 6. Continuity of care 7. Prompt access to care

8. Template of the future: escape from 15-minute visit 9. Coordination of care 10. Conscious and trained leadership

Template of the past Time

Primary care physician

Medical assistant

Nurse

Nurse Practioner

Medical assistant

8:00

Patient A

Assist with Patient A

Triage

Patient H

Assist with Patient H

8:15

Patient B

Assist with Patient B

Injections

Patient I

Assist with Patient I

Patient J

Assist with Patient J

Patient K

Assist with Patient K

Patient L

Assist with Patient L

8:30

Patient C

Assist with Patient C

Wounds A bit of time left for patient education

8:45

Patient D

Assist with Patient D

9:00

Patient E

Assist with Patient E

9:15

Patient F

Assist with Patient F

Patient M

Assist with Patient M

9:30

Patient G

Assist with Patient G

Patient N

Assist with Patient N

Template of the Past Future Time

Primary care physician

Medical assistant 1

8:00

Patient A

Assist with Patient A

8:10

E-visitsB Patient and phone C Patient visits

Assist with Panel Patient B manage-

8:30 9:00

ment Assist with Patient C

10:00

Triage Huddle Patient H RN Care

management

Medical Assistant 2 Assist with Patient H

Assist with PatientAcute I Patient I Patients Assist with Patient J

Assist with Complex Patient D patient

Patient K

Assist with Patient K

Assist with Complex Patient E patient

E-visitsL Patient

Assist with Panel Patient L manage-

Patient E

Coordinate with Patient F hospitalists and specialists

10:30

Nurse Practitioner

Patient J

Patient D

9:30

RN

Huddle with Patient G RN, NP

Assist BPwith Patient F

coaching clinic Assist with Patient G

and phone visits M Patient

Huddle Patient with MDN

Assist with ment Patient M Assist with Patient N

•30 patients are seen or contacted in the first 3 hours of the day

26

The road to high performance • Report forthcoming by California HealthCare Foundation on the building blocks of high performing primary care with many details • Safety Net Medical Home Initiative has excellent implementation guides www.qhmedicalhome.org/ safety-net/publications.cfm • Make site visits to high-performing clinics (Clinic Ole in Napa and Sebastopol Community Health Center may be the best in the Bay Area) • [email protected] • The road is long and hard; together we can do it

Loading...

The building blocks of high- performing primary care

The building blocks of highperforming primary care Tom Bodenheimer MD Center for Excellence in Primary Care, UCSF Optimal healthcare system design ...

2MB Sizes 0 Downloads 0 Views

Recommend Documents

Atoms: The Building Blocks of Matter - David Brearley High School
CHAPTER 3 REVIEW. Atoms: The Building Blocks of Matter. SECTION 1. SHORT ANSWER Answer the following questions in the sp

Building Blocks of Geometry
L E S S O N. 1.1. Building Blocks of Geometry. Three building blocks of geometry are points, lines, and planes. A p

Atoms: The Building Blocks of Matter
Sep 29, 2016 - Section Quiz: The Atom: From Philosophical. Idea to Scientific Theory. In the space provided, write the l

Building Blocks Competition
Riley Falconer. 19. PHS. 38.4. 384. 14. Jose Zarate, Daniel Ruiz, Simon Barrera. 3 ... Azucena Izquierdo, Charlie Hernan

Building Blocks VFIS - VFIS.com
Apr 9, 1996 - Guidelines on writing newspaper articles profiling volunteers . ..... We can call these statements––st

Workshop 6 The Building Blocks of Macroeconomics
Form groups and answer the questions in Lesson 6.1, “All About GDP.” (23 minutes) Discuss the answers to the followi

Project: Building Blocks | The Odin Project
In cryptography, a Caesar cipher, also known as Caesar's cipher, the shift cipher, Caesar's code or Caesar shift, is one

Paragraphs: The Building Blocks of Writing - The University of
Paragraphs: The Building Blocks of Writing. “I would argue that the paragraph, not the sentence, is the basic unit of

High School & Mater Performing
Scholarship Application Fact sheet: http://apps.carleton.edu/summer/assets/2017_Scholarship_Information_Page.pdf .... F

10 Leadership Techniques for Building High-Performing Teams
And it all comes down to leadership. In every case that has been studied at the Europe-based Centre for Organizational R