Transforming Primary Care at Group Health Cooperative
April 16, 2010, Clarissa Hsu PhD, Center for Community Health and Evaluation part of the Group Health Research Institute QualisHealth Webinar
Presentation Goals
• Revitalizing primary care: the medical home imperative • Defining the medical home at Group Health • Getting from here to there: implementing practice redesign • Our medical home learnings • What’s next at Group Health?
About Group Health… •Integrated health insurance & delivery system •Founded in 1946 •Consumer governed, non-profit •Membership: 628,000 Staff: 9,390 •Revenues (2008): $2.8 billion •Integrated Group Practice •Multispecialty Group Practice •• 26 26 primary primary care care medical medical centers centers •• 6 1 hospital 6 specialty specialty systems, units, 1 hospital •~900 physicians • 960 physicians •Contracted •Contracted network network •> • >9,000 9,000pracititioners, practitioners, 39 39 hospitals hospitals •Group Health Research Institute •32 investigators •235 active grants, $34 million (2008)
Revitalizing primary care
A little history… • Since its origin, Group Health organized around primary care base Defined practice populations Specialty care gatekeeping
Multi-disciplinary teams Salaried physicians
• Declines in financial performance & membership in early 2000s • Reforms implemented to improve access, efficiency, productivity “Advanced access” Same-day appointing Leaner primary care teams Direct specialty access EHR implementation Secure email messaging RVU-based productivity incentives (Ralston et al, Med Care Res Rev. 2009;66:703-24.)
• Reforms resulted in a faster “hamster wheel” (Tufano JGIM 2008;23:1778-83. Conrad HSR 2008;43:1888-1905.)
The medical home imperative Utilization Trends 1997-2005 by Quarter 0.9
Access & Efficiency Reforms 0.8
0.7
Frequency
0.6
Primary Care Visits Primary Care Visits
0.5
Specialty Care Visits
Specialist Visits
Inpatient Days Inpatient Admits
0.4
Emergency Department
0.3
0.2
Inpatient Days
ER Visits
Inpatient Admits
0.1
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
The medical home imperative Inpatient & ER Utilization Trends 1997-2005 by Quarter 0.09
Access & Efficiency Reforms 0.08 Inp at ient Days
0.07
Inp at ient A d mit s Emerg ency Dep art ment
Frequency
Frequency
0.06
ER Visits
0.05
Inpatient Days
0.04
0.03
0.02
0.01
Inpatient Admits 0
1997
1998
1999
2000
2001
2002
2003
2004
2005
The medical home imperative Increasing primary care physician burnout “...the way in which [care] is structured, it has shifted such an increased amount of work onto primary care that it is not sustainable … I’m actually looking to get out of primary care because I can no longer work at this pace.” “ The burnout rate among my colleagues is huge … those of us that have managed to retain some semblance of balance do it by almost unacceptable levels of compromise, either for ourselves or what we define as good enough care.” (Tufano et al, JGIM 2008;23:1778-83)
Looming primary care workforce crisis • Many positions unfilled • Full-time practice is now a rarity • Primary care MDs retiring earlier than specialists • Exit interviews show most common reason for separation: high workload
The medical home imperative
There just has to be a better way!
Revitalizing primary care
The PCMH model:
Traditional family practice values + 21st century information technology
Supported by consumers, physicians, health plans, policy makers
Whole person care across lifespan
Personalized, preventionfocused, coordinated
Until now, little empirical evidence of its benefits
Revitalizing primary care
Group Health PCMH design principles:
Proactive, comprehensive care
Physician patient relationship at the core
Patientcentered access 24/7
Coordination & collaboration with patients
Efficient, satisfying, effective
Revitalizing primary care Panel size
PCMH design: Clinical teams
2,300
1,800
Appointments 30 min. 20 min.
Desktop time
E-technology
Medical home change components PCMH Model Point-of-care changes • Calls redirected to care teams • Secure e-mail • Phone encounters • Pre-visit chart review • Collaborative care plans • EHR best practice alerts • EHR prevention reminders • Defined team roles
Patient-centered outreach • ED & urgent care visits • Hospital discharges • Quality deficiency reports • e-health risk assessment • Birthday reminder letters • Medication management • New patients
Management & payment • Team huddles • Visual display systems • PDCA improvement cycles • Salary only MD compensation
Planning and evaluation
PCMH timeline
PCMH prototype evaluation Group Health Research Institute conducted a prospective, before-and-after evaluation comparing Prototype clinic with other Group Health clinics in western Washington
PCMH prototype evaluation
Evaluation measures:
Patient experience
Staff burnout
Quality
Utilization
Cost
PCMH prototype evaluation One year evaluation results available from: http://www.ajmc.com/issue/ managed-care/2009/200909-vol15-n9
What have we learned?
Patient experience Significantly higher scores for patients at PCMH prototype clinic
Year 1
Quality of patient-doctor interactions Shared decision making Coordination of care Access Helpfulness of office staff Patient activation & involvement Goal setting & tailoring Compared to controls:
PCMH Prototype significantly higher
PCMH Prototype significantly lower
Difference not significant
Staff burnout Marked improvement in burnout levels at PCMH prototype clinic at 1 year Medical Home
Control Clinics
Emotional Exhaustion Baseline
44.4%
54.2%
12 month
19.4%
54.5%
**
Depersonalization Baseline
25.0%
12 month
25.0%
18.8%
30.4%
Lack of Personal Accomplishment Baseline
25.0%
12 month -60%
18.2% 10.0%
-40%
-20%
25.6%
0%
20%
40%
% Patient Care Employees rating as "Moderate/High"
60%
** p
