building an integrated system for personalizing care tim johnson, md spring, 2014
TRANSCRIPT
Building an Integrated System for Personalizing Care
Tim Johnson, MDSpring, 2014
Intermountain Medical Group• 1,056 physicians
• 342 primary care• 491 secondary care• 86 hospitalists• 17 radiologists• 120 urgent care
• 265 advanced practice clinicians• 81 primary care clinics
Dual Model for the Medical Home
Distributed Model Intensive Model
Distributed Model: Personalized Primary CareIntermountain Medical Group and SelectHealth Modeled on 2011 PCMH NCQA StandardsTeam members
• Primary Care Clinician• RN Care Manager• MA Health Advocate(s)• Advanced Practice Clinicians• Doctor of Pharmacy• Mental Health Integration
Personalized Primary CareImplementation 2010 - 2014
• 64 adult primary care clinics• 17 pediatric clinics• 345 physicians and advance
practice clinicians• ~100 care managers and health
advocatesHybrid model: central and region leadershipLevel 2 and level 3 within 2-3 years
Personalized Primary Care: Results
20%
35%Intermountain diabetes bundle: HgbA1c < 8% LDL < 100 BP < 140/90 Annual nephropathy screen Eye exam every 2 years
48%
50%
52%
54%
56%
58%
60%
62%
64%2013 Stretch Goal
1 2 3
PPCsAll
Clinical Quality
Patient Satisfaction
Years after Implementation
Allowed Per Member Per Month
Total Cost Trend*
*Preliminary results, risk-adjusted and normalized for contractual payment differences
Intensive Model: Personalized Care Clinic
• An outpatient clinic that provides intensive medical, behavioral, and social management for Intermountain’s high-risk patients
• Patients in the top 5-10% of costs for 2 of the last 3 years
Personalized Care Clinic: The Team
• Internal Medicine Physician• Palliative Care Physician (0.2)• RN Care Manager• Psychiatry APRN• LCSW• Pharmacist
• 2 Medical Assistants• PSR• Clinic Manager• Assistant Region Operations
Officer• Region Medical Director
Personalized Care Clinic: Process of care
• Acts like a primary care office with more resources to coordinate care, address mental health conditions, and manage complex medication issues
• Ensure patients receive care in appropriate setting – focus on acute care utilization
• Coordinate and collaborate with all of the patient’s specialists
• Committed to eliminating all avoidable health care emergencies
Your comments and questions…