National Healthcare Reform: The Primary Care Imperatives And Strategies For Meeting Them

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National Health Reform: The Primary Care Imperatives and Strategies for Meeting Them Presentation to the American Public Health Association Medical Care Section Avedis Donabedian Award in Quality Improvement Session

Ronda Kotelchuck, Executive Director Primary Care Development Corporation Tuesday, November 10, 2009

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Overview A.

Introduction

B.

Health Care Reform: The Primary Care Agenda

C. Primary Care Expansion D. Primary Care Transformation

E.

1.

Practice Redesign

2.

Health Information Technology

Reflections

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A. Introduction: Convergence of Public Health and Primary Care to Reduce Chronic Illness •

Chronic illness has become the new frontier of public health – – – –

•

Single largest cause of morbidity and mortality Accounts for 75% of all health expenses Heaviest impact on low income communities Will grow more severe as population ages

Primary care providers play a critical role in prevention – Integral to all three phases of prevention; • Primary: Preventing the onset of illness • Secondary: Early identification and intervention • Tertiary: Preventing complications and maintaining the highest level of functioning

– Powerfully positioned to influence lifestyle choices driving chronic illness – New models of primary care take responsibility for patient panels and population health All rights reserved. PCDC 2009

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Primary Care Today: Insufficient and Poorly Organized • Primary care capacity is insufficient: – – – –

60 million Americans lack access to primary care Half of primary care doctors plan to reduce or end their practices Only 20 percent of medical students plan to practice primary care U.S. is expected to need 46,000 primary care doctors by 2025

• Most primary care is poorly organized and still practiced in an outdated mode. It is: – – – –

Reactive and episodic Subject to long waits and delays Uncoordinated Inefficient

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Study: US Lags Behind other Countries in Key Primary Care Indicators • 11 country Commonwealth Fund study (November 2009) – Australia, Canada, France, Germany, Italy, Netherlands, New Zealand, Norway, Sweden, UK, US • US 10th out of 11 in use of Electronic Medical Records (46% - ahead of Canada) • 10th of 11 in use of care teams (ahead of France) • Last in access to after-hours care • Least likely to have financial incentives for clinical outcomes

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B. The Primary Care Agenda: Health Reform Will Increase Demand for Primary Care – Expanded insurance coverage will put millions of new customers in the healthcare market – Physician shortages will increase by 25% and workload by 29% over the next 15 years. – The Massachusetts experience: • 97% coverage • 40% of family physicians are not accepting new patients • Patients wait months for appointments • Record use of ER for non-emergencies

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Rising Costs Will Drive the Need to Transform Primary Care Delivery • Growing evidence shows that primary care is effective in reducing costs, improving health outcomes and eliminating disparities • Employers, insurers and policymakers are looking to primary care as the new paradigm for control costs and increasing improving outcomes. • A new model of care is necessary, however, to achieve these objectives. • Innovations in practice have been afoot for years (practice redesign, evidence-based clinical protocols, etc.) • Now these are integrated into the concept of the PatientCentered Medical Home All rights reserved. PCDC 2009

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PCDC: Strategies for Primary Care Expansion and Transformation • Non-profit organization founded in 1993 to address the lack of good primary care in underserved communities • Premier public-private partnership focused on needs of safety net providers - community health centers, hospitals, special needs providers • Three areas of expertise – Capital Financing – Performance Improvement – Policy All rights reserved. PCDC 2009

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C. PCDC Primary Care Expansion Strategy Problem: – Lack of capital constrains growth of long-standing, dedicated providers of care to the underserved; further hampered by the current credit crisis

Strategy: – Use public funds to leverage private investment – Provide favorable-term loans to catalyze construction of new, expanded and renovated sites, modernized facilities – Technical assistance to ensure successful project completion and long-term sustainability

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Results • Total investments of $240 million for 78 capital projects in New York State • Created capacity for 550,000 new patients/1.7M visits annually • Leverage more than 1:5 public:private investment • Cornerstone of local economic development: 2,200 permanent jobs created; 4,400 with community multipliers • Facilities operating successfully, no defaults

•PCDC Capital Projects (partial list)

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Joseph P. Addabbo Family Health Center Queens, NY

Before

After

$9.4 million for new facility Renovated 22,000 square feet Increased patient visits by 40% All rights reserved. PCDC 2009

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Callen-Lorde Community Health Center Chelsea, NY

After Before

$9.3 million for relocation & expansion Increased patient visits from 8,000 to 48,000 annually All rights reserved. PCDC 2009

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Reflections on Capital Strategy for Expansion • • • • • •

Technical assistance is critical for organizations that have little experience or internal capacity for undertaking a complex, expensive, risky process Partnership among stakeholders is key since the respective costs are spread among different parties; all have high stakes in its success Relative ease of raising capital Creates a permanent community infrastructure The resulting knowledge and relationships provide a great foundation for other initiatives (e.g., transformation; policy) Offers a replicable model to address the capacity crisis that will follow national health reform

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D. The Need for Transformation • Origin: Initial focus on financial strength of borrowers • Discovery of the gap between what is possible and what is. • New realization: Much capacity goes unused because of poor processes. • Poor processes themselves become barriers to access • Waits for appointments; lengthy cycle times; high noshows; staff-focused rather than patient-focused processes; poor customer service • The promise of a new primary care model: the medical home

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A Vision of Transformation: The Patient-Centered Medical Home • The medical home concept: – Continuity – Well organized (efficient) practice – Access: Same day appointment availability, 24/7 telephone access, alternatives to the 1:1 visit – Responsibility for health outcomes • • • •

Panel management Decision support Incorporation of evidence based practice (prevention, treatment, management) Care coordination across settings

– Patient /family engagement

• Formalization: – Principles agreed to by major professional associations – NCQA standards, measures, system of recognition

• Growth of the medical home movement All rights reserved. PCDC 2009

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PCDC Performance Improvement Programs: Strategies for Transformation 1.

Medical Home – Assist providers to achieve NCQA recognition and transformation (also 2 programs below) Practice Redesign – Expand access and achieve efficiency by eliminating wait times--both for appointments and during the visit— increasing through-put (productivity), improving patient and staff satisfaction and increasing revenues. HIT Implementation and Meaningful Use – Adopt and integrate technology to improve quality, coordinate and manage care, engage patients and improve patient-provider communication. Other PCDC Performance Improvement Programs:

2.

3. 4. • • •

Attracting and Retaining Patients Increasing Revenue Primary Care Emergency Preparedness

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Performance Improvement – PCDC Approach •

Focus on: – Implementation – System Design – Measurable Results – Staff Organized as Care Teams – Building Client Capability – Sustainability

•

Use of: – Change Teams – Coaching and Training – Collaborative Learning – Project Management – Frameworks for Improvement • Model for Improvement • Chronic Care Model • Medical Home Model • Change Concepts & Tactics

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1. Medical Home Transformation Issue: •

Medical home transformation is a difficult, risky, expensive process with many facets and many entry points.

What We Do • Facilitate the NCQA Recognition Process – Tools for Safety Net Providers (Just launched) – Consultation and Technical Assistance for Achieving Recognition • Project Management • Assessing Status and Setting Goals for Level of Recognition • Plan for completing NCQA application; focus on documentation requirements

•

Assist in Practice Transformation • Access and Workflow Redesign • Clinical Care Teams • Care Model Implementation – Care Coordination and Management – Planned Care and Self Management • Meaningful Use of HIT in support of functional transformation to medical home

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2. Practice Redesign: a. Reducing Patient Visit Wait Time The Issues: • Patient visits often average 2 to 3+ hours (for 15 minutes of actual face-time). • Long cycle times: signature of poorly organized, inefficient work processes • Well-organized, patient-focused work processes: basis for all other improvements. What We Do: • Work with leaders to establish goals and select a change team. • Train and coach team to measure baseline cycle time, track and map current patient visit flow • Teach/share change concepts and principles for redesign, including – Bring services to the patient, 2 exam rooms per provider – Organize care teams with adequate provider support; leverage provider time – Plan and prepare for the day (e.g., huddles, supplies, equipment) – On-time performance – Real-time communication – Do today’s work today • Support the Change Team in developing, testing, and refining new patient visit flow over 6-8 week period; spreading to full clinic (2 to 4 weeks); anchoring for sustainability (3 months)

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2. Practice Redesign: b. Accelerating Appointment Availability The Issues: • • •

Patients often wait 3-6 weeks for an appointment; instead go to the ER No shows run as high as 50-60%; providers overbook to make up for no shows Organizations operate well below capacity (25-35%)

What we do: • •

Focus on continuity; establish right-sized patient panels Balance: Optimizing capacity (efficiency processes); moderating demand (care team & clinical processes) – Reduce no-shows; fully utilize reminder calls; eliminate overbooking; see drop-ins – Create permanent capacity for same day appointments; standardize appointment types – Eliminate appointment back-logs; unnecessary visits – Efficient flow: Use of care team; on-time performance; planning and preparation; teamwork; communication – Rethink methods of providing services: Telephone, e-mail, group visits All rights reserved. PCDC 2009

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Practice Redesign Results • Trained 219 teams • No show rates decrease by nearly 70% • Appointment backlogs drop from an average of 21 days to 0-5 days • Cycle time reduced 50% (to an average of 51 minutes) • Provider productivity increase of 33% • Improved patient and staff satisfaction

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3. Implementation and Meaningful Use of HIT The Issues: • • • •

Difficult, expensive, risky process Organizations with little experience or internal capacity, few resources Excessive, vendor-generated information; little ability to evaluate Lack of resources (need for sector advocacy, partnership)

What we do: TA for all stages of HIT adoption • •

HIT vendor selection and contracting Planning and readiness – Internal capacity: team building, staff training, project management – Design (workflow, decision support) – Budgeting

• •

Implementation and go-live Effective use (Assure “meaningful use” compliance) – Data reporting (Quality, compliance, panel management) – Health information exchange

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HIT Results •

Program – Coached 38 teams through various HIT phases; to date: • Selection: 23 • Planning and readiness: 11 • Go-lives: 6 • Health information exchange: 6 • Quality use: 2 – Remediation: 1 – AHRQ research project on use of HIT Clinical Decision Support.

•

Advocacy – Co-founded the Primary Care Health Information Consortium (29 health centers) – State grant program – City Council infrastructure support

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E. Reflections: The Nature of Organizational Change •

The under-appreciation of implementation – People know what needs to be changed. They lack knowledge of how to change – Transforming the model of primary care requires major, thorough-going organizational and cultural change. – Myths: • It can been done “fast and cheap” • It’s a project. Once done, we can move on to other things. • It can be delegated from the top – The importance of technical assistance, willingness to invest in the change process

•

The under-appreciation of everyday operations – Practice redesign, HIT as preconditions for clinical improvements, quality All rights reserved. PCDC 2009

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Reflections: Keys to Success • The importance of leadership – Understanding of the leadership role and the model for change – Setting of expectations; demanding results and accountability; establishing systems of accountability – Building of a leadership coalition – Engagement – The difference between internal and external leadership skills

• Change must be anchored in the everyday business of the organization – Policies and procedures; job descriptions, recruiting hiring, training, performance appraisal. – Monitoring, performance reporting

• The importance of teams – Implications for workforce development, unions, staff roles, organizational culture

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Reflections on Safety Net Settings •

Private practice – – – –

•

Community Health Centers – –

•

FQHCs offer robust model, many PCMH functions, experience in quality improvement Continuity, access, efficiency not assured

Special Needs Providers –

•

Strong on continuity and access Isolation raises concerns about quality, coordination Setting is simpler, change is easier Small size, spare resources pose a challenge to acquiring HIT, adding PCMH functions.

Already offer a “care home”, instinctually understand medical home

Hospital OPDs – – –

Broad scope of service available (specialties, ancillaries) Continuity, access, efficiency present challenge in teaching environment Primary care is not the institutional focus or priority

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Reflections: PCDC as a Model for Addressing the Two Challenges: Expanding and Transforming Primary Care • • • • • • • • • •

Generates resources: Total: $315M ($62M public, $253 private) Produces measurable, sustainable outcomes Ability to reach scale Builds lasting community infrastructure Catalyzes important community economic development Offers excellent platform upon which to build additional programs and services Works across wide range of provider types (community health centers, hospitals, private practitioners) The importance of an organization dedicated solely to primary care Builds a strong community of interest in the success of primary care. Is adaptable to localities, states, foundations

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Contact Ronda Kotelchuck Executive Director Primary Care Development Corporation Phone: (212) 437-3917 E-Mail: [email protected]

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Excellent Healthcare in Every Neighborhood. 22 Cortlandt Street 12th Floor New York, NY 10007 P: (212) 437-3900

l

www.pcdcny.org

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