the doctor is in! best practices in medical home journey angelo p. giardino, md, phd, mph medical...
TRANSCRIPT
The Doctor is In! Best Practices in
Medical Home JourneyAngelo P. Giardino, MD, PhD, MPH
Medical DirectorTexas Children’s Health PlanClinical Professor, Pediatrics
Baylor College of Medicine
A discrepancy between what we know and how we practice 2003 RAND study“Half of patients don’t get right thing done”
• 55% “right things” done for preventive services• 54% right things for acute care• 56% for chronic care• 79% for cataracts• 11% for alcoholism
McGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003; 348;26:2635-45.
Quality Mismatch - Adults
Quality Mismatch - ChildrenA discrepancy between what we know
and how we practice 2007 RAND study“Half of patients don’t get right thing done”
• 47% “right things” done for indicated care• 68% right things for acute care• 54% for chronic care• 41% for preventive• 92% for upper respiratory tract infections• 35% for preventive services for adolescents
Mangione-Smith, R. et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 2007;357;15:1515-1523.
A Team Approach To Care
Shared Responsibility for Quality and Cost
Fostering A Culture Of Improvement
Medical Home Capabilities
• Team approach to care• Registries for the top few diagnoses• Pro-active care coordination• Quality systems and measurement built in• Partnership with community resources• Advanced patient education and self
management support• Service orientation• Information technology support
Care Coordination
• Using the registry to assure that everyone on the list gets the indicated care on a timely basis
• This is a team responsibility not an FTE
• Arrange appointments, follow-up, lab and educational opportunities
• Standing orders
Quality Systems Built In
• Flow sheets, reminders and checklists• Collect data for clinical measures at
the time of care• Use nationally endorsed measures• Report the data for comparison
purposes• Use the data to drive process
improvement in the office microsystem
Community Resources
• Disease specific educational or support services
• Engaging family and caregiver support
• Partnering with disease management programs provided by health plans
• Home care services when necessary
Time Spent on Care Coordination
PCP<1%
(87)
Office Staff15%(3118)Other
4%756
Care Coordinators76% (15,496)
Social Worker5%(951)
020406080
100120140160180200220240260280
1900 1920 1940 1960 1980 2000 2004
From Overpeck (7) From AMA
Total Physicians and FP/GP per 100,000 Population
TotalTotal physiciansphysicians
FP/GPFP/GP
300
From Silver (2)
American Academy of Family Practitioners
0
10
20
30
40
50
60
GP/FP
GIM
G Ped
G Sur
GOB
Physicians per 100,000 Population — 2000 (Total MD’s)
00--0-2,499 2,500--
4,999
5,000--
9,999
10,000--
24,999
25,000--
49,999
50,000--
199,999
200,000--
999,999
1,000,000--
2,999,999 3,000,000+
Ph
ysic
ian
s p
er
100,
000
Population Size Of The Community
Rural Small Town Suburban Urban
American Academy of Family Practitioners
The Primary Care PhysicianNumber of Office Visits to Primary Care Physicians vs. Other Specialists1
0
100
200
300
400
500
Fami ly/ General
Practi ce
Internal
Medicine
Pediatr i cs Al l Pr imary
Care
Other
Special i sts
208 Million
146 Million
117 Million
471 Million 440
Million
23% 16% 13%
52%48%
American Academy of Family Practitioners
Characteristics of Practices in Transformation
•Successful• Positive attitude• True sense of team• Process mapping• Systematic
approach• All participate and
are respected for their contribution
•Stuck in the mud
• Victim vocabulary• Command and
control• Wondering why• Just trying harder• Physicians
unapproachableAmerican Academy of Family Practitioners
ReferencesMcGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003; 348;26:2635-45.
Mangione-Smith, R. et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 2007;357;15:1515-1523.