An Opportunity for Senior Living Provider Systems?

American society is experiencing growth in its elderly residents that is unprecedented in the history of the world

It is anticipated that by 2030 the US will have approximately 76 million residents over the age of 65

Many experts believe that the US is wholly unprepared to meet the many complex needs of a large elderly society and that we need to steps now to address this need in the areas of:

• Affordable housing for seniors• Support services related to senior living needs• Improved transportation• Significant deficits in access to healthcare for seniors

Access to quality healthcare may be the single most challenging issue facing seniors in the next 2 decades

• Severe shortage of primary care physicians and geriatricians• The average 75 year old has 3 chronic conditions and takes 4 meds• Poor services to treat chronic illnesses• Fewer SNF beds available• More single households making access to care more problematic

Alzheimer’s Disease will exacerbate access to care problems• It is anticipated that 1 in 8 seniors will have Alzheimers

As more barriers to access to healthcare for seniors develop, it is important that we find new models for health care delivery to our senior population.

One such model of alternative health care delivery that is currently under review is the Patient-Centered Medical Home (“PCMH”).

This morning, we are going to examine the PCMH and discuss whether PCMH provides a significant opportunity for senior living providers to make a value-added contribution to the health care needs of our elderly population.

DISCUSSION

1. PCMH. Dr. Michael Goran will provide information and background concerning PCMH.

2. Application to Senior Living Providers. Following Dr. Goran’s explanation of PCMH we will use the Roundtable to discuss whether the implementation of a PCMH may provide a viable strategy for senior living providers.

Dr. Michael Goran

Patient-Centered care is one of the key components of quality health care called for by the IOM in 2001

“The PCMH is the best opportunity for aligning physicians, patient frustration, demonstrated models for improving care, and private and public payment systems to produce the most profound transformation of the health care system in anyone’s memory.” (Robert Graham Center, November 2007)

“The future of primary care is at great risk at a time when the evidence suggests that the nation needs primary care more than ever.” (American College of Physicians, 2009)

Many areas of the nation are currently experiencing shortages in PCPs and unless there is fundamental change the shortage of primary care physicians will grow to 124,000 by 2025 (American College of Physicians, 2009)

Physician payment reforms are needed to adequately compensate PCPs to provide patient-focused, coordinated care and to acquire the health information technology necessary to provide such care• Traditional payment systems reward physicians for increasing

volume of visits and procedures• Traditional payment systems do not provide incentives to

coordinate care• And provide no mechanism for physicians to share in the savings

that physician-guided care coordination activities generate Primary care physicians require technical assistance to reorganize

their practices into modernized PCMHs (A Lifeline for Primary Care, Bodenheimer, et al., NEJM)

“The PCMH is an approach to providing comprehensive care for children, youth and adults. The PCMH is a health care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family.” (Joint Principles of the PCMH, March 2007, AAFP, AAP, ACP, AOA)

Personal physician—each patient has an ongoing relationship and receives continuous, comprehensive care

Physician directed medical practice—physician led team collectively take responsibility for the ongoing care of patients

Whole person orientation—responsible for all the patient’s health care needs including arranging care with qualified professionals for all stages of life; acute, chronic, preventive and end of life

Care is coordinated and/or integrated—across all elements of complex health care system including subspecialty care, hospitals, home health agencies, nursing homes and the patient’s community. Care is facilitated by registries, HIT and exchange of information

Quality and safety—practices advocate for their patients to attain optimal outcomes that are defined by a care planning process driven by a compassionate partnership between patient and the care team. PCMH is accountable for continuous quality improvement. Patients actively participate in decision-making and feedback. HIT is used to support optimal patient care, performance measurement, patient education and enhanced communication. Practices go through a voluntary recognition process

Enhanced access—open scheduling and new options for communication between patients and their care team

Payment reform—recognizes added value provided to patients who have a PCMH

American Academy of Pediatrics introduced the term medical home in 1967

WHO adopted basic tenets of the medical home in 1978 IOM embraced the concept of patient-centered care and the medical

home in 1990 PCMH draws extensively on concepts of Ed Wagner’s Chronic Care

Model (Group Health of Puget Sound)

Patient care will be provided through a multidisciplinary team and will be dependent on a deep understanding of the population served by the practice. (FFM Task Force 1 Report)

“Integration is complex, time-consuming work; improving primary care’s performance in integrating care will involve an effort akin to that of improving safety.” (Robert Ferrer, et al.)

“Rather than uncoordinated, episodic care, we need to offer care that is well organized, coordinated, integrated, characterized by effective communication, and based on continuous healing relationships.” (Eric Larson)

PCMH model will facilitate improved communication between the PCP and the referred specialist or subspecialist

Unlike gatekeeper, PCMH will not limit appropriate referrals PCMH will have systems in place to communicate more effectively

with consultants and co-management colleagues PCMH model will decrease inappropriate and unnecessary referrals PCMH model provides for specialty or subspecialty practices to be

the principal care physician for a subgroup of patients with complex conditions such as:• Difficult to control diabetes• Inflammatory bowel disease or hepatitis• HIV• Severe rheumatoid arthritis• Advanced heart failure• Malignancy

PCMH is the central hub of care—the location that is responsible for the overall coordination of the patient’s care• PCMH practice must have in place the structural capability to

assume the role of overall coordinator of care Systems to track patient referrals and treatments, medications,

diagnostic tests and laboratory results Ability to communicate this information to other participating

healthcare teams and to the patient• PMCH practice will have formal or informal agreements with each

referred to or care co-managing specialty or subspecialty provider regarding coordination of care

PCMHs can be the primary care foundation of Accountable Care Organizations

PCMHs will deploy advanced technology such as Remote Patient Monitoring and broad band Telemedicine to improve outcomes for patients with complex and/or multiple chronic diseases

Publically available

information

•Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

8Source: Health2 Resources 9.30.08

Defining the Medical Home(Slide from Patient-Centered Primary Care Collaborative)

TODAY’S CARE MEDICAL HOME CARE

My patients are those who make appointments to see me

Our patients are those who are registered in our medical home

Patients’ chief complaints or reasons for visit determines care

We systematically assess all our patients’ health needs to plan care

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Acute care is delivered in the next available appointment and walk-ins

Acute care is delivered by open access and non-visit contacts

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

NCQA is developing/testing certification program with 3 levels of recognition and 10 must pass elements

Includes measures• Access/communication• Patient tracking/registry function• Care management• Patient self-management support• E-prescribing• Test/referral tracking• Performance reporting• Advanced electronic communication

Web-based data collection tool Scoring

• Level one (must pass 5 of 10 elements at 50% and have 25-49 points)

• Level two (must pass all 10 elements at 50% and have 50-74 points)• Level three (must pass all 10 elements at 50% and have 75+ points)

Standard 1: Access and CommunicationA. Has written standards for patient access and patient communication**B. Uses data to show it meets its standards for patient access and communication**

Pts

459

Standard 2: Patient Tracking and Registry FunctionsA. Uses data system for basic patient information(mostly non-clinical data)B. Has clinical data system with clinical data insearchable data fieldsC. Uses the clinical data systemD. Uses paper or electronic-based charting tools to organize clinical information**E. Uses data to identify important diagnoses and conditions in practice**F. Generates lists of patients and reminds patients and clinicians of services needed (population management)

Pts

2

33

64

321

Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines for three conditions **B. Generates reminders about preventive services forcliniciansC. Uses non-physician staff to manage patient careD. Conducts care management, including care plans,assessing progress, addressing barriersE. Coordinates care//follow-up for patients whoreceive care in inpatient and outpatient facilities

Pts

3

43

55

20

Standard 4: Patient Self-Management SupportA. Assesses language preference and othercommunication barriersB. Actively supports patient self-management**

Pts

246

Standard 5: Electronic PrescribingA. Uses electronic system to write prescriptionsB. Has electronic prescription writer with safety checksC. Has electronic prescription writer with cost checks

Pts3328

Standard 6: Test TrackingA. Tracks tests and identifies abnormal resultssystematically**B. Uses electronic systems to order and retrieve tests and flag duplicate tests

Standard 7: Referral TrackingA. Tracks referrals using paper-based or electronicsystem**

Pts

7613Pts44

Standard 8: Performance Reporting andImprovementA. Measures clinical and/or service performanceby physician or across the practice**B. Survey of patients’ care experienceC. Reports performance across the practice or byphysician **D. Sets goals and takes action to improveperformanceE. Produces reports using standardized measuresF. Transmits reports with standardized measureselectronically to external entities

Pts

3

33

321

15

Standard 9: Advanced Electronic CommunicationsA. Availability of Interactive WebsiteB. Electronic Patient IdentificationC. Electronic Care Management Support

Pts1214

**Must Pass Elements

NCQA PPC-PCMH Content and Scoring

NCQA PPC-PCMH Scoring

Level of Qualifying

Points Must Pass Elementsat 50% Performance Level

Level 3 75-100 10 of 10

Level 2 50-74 10 of 10

Level 1 25-49 5 of 10

Not recognized 0-24 <5

Levels: If there is a difference in Level achieved between the number of points and “Must Pass”, the practice will be awarded the lesser level; for example, if a practice has 65 points butpasses only 7 “Must Pass” Elements, the practice will achieve at Level 1.

Practices with a numeric score of 0 to 24 points or less than 5 “Must Pass” Elements are not Recognized.

A prospective, per patient, per month bundled care coordination component (risk adjusted for patient severity and for how advanced a practice is in HIT). The care coordination fee would also include services such as the time that physicians and their staff spend on coordinating care with family caregivers or other clinicians

A fee-for-service payment for the face-to-face encounters with patients

A performance-based component based on the achievement of defined quality, cost or care and patient experience measures

Key physician and practice accountabilities/ value added

services and tools

Proactively work to keep patients healthy and manage existing illness or conditions

Coordinate patient care among an organized team of health care professionals

Utilize systems at the practice level to achieve higher quality of care and better outcomes

Focus on whole person care for their patients

Performance Standards

Incentives

Incentives

Incentives

16

27 pilot programs in 20 States 8 Medicare pilots planned for 2009 44 States and District of Columbia have passed over 330 laws

and/or have PCMH activity Health Reform bills propose expansion of PCMH activity As of January 2009, 28 BCBS Plan Pilots Cigna pilot in NH; Aetna has pilots in CO, ME, NY, PA, and NJ;

Wellpoint has pilot in NY; UnitedHealth has pilot in AZ PPPCC in its third year has multiple stakeholders, 550 members

committed to advancing PCMH concept

The Patient-Centered Primary Care Collaborative

ACP

Providers 333,000

primary carePurchasers –Most of the Fortune 500

Payers Patients

AAP AAFP AOA ABIM ACC ACOI AHI

IBM Ohio

General Electric

FedEx

Microsoft

Dow

Merck & Co.

Business Coalitions

BCBSA United

Aetna

CIGNA

Humana

WellPoint

Kaiser Permanente

AARP AFL-CIO National Consumers League

SEIU Foundation for Informed

Decision Making

Examples of Broad Stakeholder Support & Participation

The Patient-Centered Medical Home 80 Million lives

Geisinger

Iowa

PCMH improves access to needed care, increases utilization of preventive screenings, and improves management of chronic conditions (Commonwealth Fund)

Rigorous evaluation of 4,000 patients with diabetes, congestive heart failure, asthma and depression with care provided according to PCMH principles (RAND and UC Berkeley)• Patients with diabetes had significant reductions in cardiovascular

risk• CHF patients had 35% fewer hospital days• Asthma and diabetes patients were more likely to receive appropriate

therapy NC Medicaid program saved $224M per year by enrolling recipients in a

network of PCMHs (Mercer) Denmark has organized its entire health care system around PCMHs

and has the highest patient satisfaction ratings in the world and among the lowest cost per capita health expenditures (Commonwealth Fund)

Care delivered by primary care physicians in a PCMH is consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, improved patient compliance with recommended care, and lower costs (Patient-Centered Primary Care Collaborative)

Pilot: Geisinger Health System

Lewisburg

Pennsylvania

Pre-Test period

Jan - Oct 2006

First pilot year

Jan – Oct 2007 Percent

reduction

Hospital Admission 365/1000 291/1000 - 20%

Hospital readmissions 15.2% 7.9% - 48%

Cost 7% less

An Opportunity for Senior Living Provider Systems?

Larry Garcia

We offer the following hypotheses to the Roundtable for discussion:

Offering a PCMH on the campus of a senior living provider represents an important branding and marketing opportunity for a senior living provider.

Operating a PCMH, either a direct service or under a joint venture with a health care provider system, represents an important clinical and business opportunity for a senior living provider.