Overview-The-Primary-Care-Development-Corporation概述課件

1、National Health Reform: The Primary Care Imperatives and Strategies for Addressing ThemPresentation to the Center for Family and Community MedicineColumbia University Medical CenterRonda Kotelchuck, Executive DirectorPrimary Care Development CorporationThursday, January 21, 2010Introduction: The Pro

2、blemsHealth Care Reform: The Primary Care AgendaPrimary Care ExpansionPrimary Care TransformationA. Practice Redesign B. Health Information TechnologyLessons and ReflectionsOverview1. Introduction: The ProblemsRising Cost and the Role of Chronic IllnessThe rising cost of health care is unsustainable

3、Cost is driven by the rising rate of chronic illness. It:Is the single largest cause of morbidity and mortalityIs the single largest driver of cost (accounts for 75% of all health expenses) Has the heaviest impact on low income communitiesWill grow more severe as population agesChronic illness is ov

4、erwhelmingly preventable or primary care manageable. Prevention and management require a robust model of primary care.Primary Care Today: Insufficient and Poorly Organized Primary care capacity is insufficient:60 million Americans lack access to primary careHalf of primary care doctors plan to reduc

5、e or end their practicesOnly 20 percent of medical students plan to practice primary care U.S. is expected to need 46,000 primary care doctors by 2025Most primary care is poorly organized and still practiced in an outdated mode. It is:Reactive and episodicSubject to long waits and delaysUncoordinate

6、dInefficientStudy: US Lags Behind other Countries in Key Primary Care IndicatorsCommonwealth Fund study of 11 countries (November 2009) Australia, Canada, France, Germany, Italy, Netherlands, New Zealand, Norway, Sweden, UK, USUS 10th out of 11 in use of Electronic Medical Records (46% - ahead of Ca

7、nada)10th of 11 in use of care teams (ahead of France)Last in access to after-hours careLeast likely to have financial incentives for clinical outcomes2. Health Care ReformThe Primary Care AgendaHealth Reform Will Drive the Need for Expanded Primary Care CapacityExpanded insurance coverage will put

8、millions of new customers into the healthcare market Physician shortages will increase by 25% and workload by 29% over the next 15 years.The Massachusetts experience: 97% coveragePatients wait months for appointments40% of family physicians are not accepting new patientsRecord use of ER for non-emer

9、gencies Rising Costs Will Drive the Need to Transform the Model of Primary CareGrowing evidence shows that primary care is effective in reducing costs, improving health outcomes and eliminating disparitiesEmployers, insurers and policymakers are looking to primary care as the new paradigm.A new mode

10、l 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 Patient-Centered Medical Home (PCMH)PCDC: Offering Strategies for Primary Care E

11、xpansion and TransformationNon-profit organization founded in 1993 to address lack of primary care access in underserved communitiesPremier public-private partnership focused on needs of safety net providers - community health centers, hospitals, special needs providersThree areas of expertiseCapita

12、l FinancingPerformance ImprovementPolicy3. PCDC:Strategies for Expanding Primary Care ExpansionPCDC Primary Care Expansion StrategyProblem:Lack of capital constrains growth of long-standing, dedicated providers of care to the underserved; further hampered by credit crisisStrategy:Use public funds to

13、 leverage private investment Provide favorable-term loans to catalyze construction of new, expanded and renovated sites, modernized facilitiesProvide:Technical assistance for facility developmentProvide strong oversight to ensure successful project completion and long-term sustainability ResultsTota

14、l investments of $245 million for 78 capital projects in New York State Created capacity for 550,000 new patients/1.7M visits annuallyLeverage more than 5:1 private:public investment Cornerstone of local economic development: 2,200 permanent jobs created; 4,400 with community multipliersFacilities o

15、perating successfully, no defaultsPCDC Capital Projects (partial list)Joseph P. Addabbo Family Health Center Queens, NYBeforeAfter$9.4 million for 22,000 SF new facility; increased patient visits by 40%Callen-Lorde Community Health Center ChelseaBeforeAfter$9.3 million for relocation & expansionIncr

16、eased patient visits from 8,000 to 48,000 annuallyReflections on Capital Strategy for ExpansionPartnership among stakeholders is keyCreates a permanent community infrastructureRelative ease of raising capitalBuilds a baseline of knowledge and relationships that provide great foundation stones for ot

17、her initiatives (e.g., transformation; policy)Technical assistance is critical for organizations that have little experience or internal capacity for undertaking a complex, expensive, risky processOffers a replicable model to address the capacity crisis that will follow national health reform4. PCDC

18、:Strategies for Transforming the Primary Care ModelThe Need for TransformationOrigin: Initial focus on financial strength of borrowersNew realization: Poor work processesCause much capacity to go unusedBecome important barrier to accessResult in inefficiency and wasteUndermine financial strengthDemo

19、ralize staff and patients.Hallmarks of poorly organized processes:Long waits for appointments; lengthy cycle times; low productivity; high no-shows; staff-focused (rather than patient-focused) processes; poor customer service Discovery of the gap between what is possible and what is.Whats possible?

20、Care that is safe, effective, patient-centered, timely, efficient and equitable (six Aims of the IOMs Crossing the Quality Chasm)The promise of a new primary care model: the medical homeA Vision of Transformation:The Patient-Centered Medical HomeThe medical home concept:ContinuityWell organized (eff

21、icient) practiceEasy access: Same day appointments, 24/7 telephone access, alternative accessResponsibility for health outcomesPanel managementCare coordination across settingsDecision supportIncorporation of evidence based practice (prevention, treatment, management)Patient /family engagementFormal

22、ization and the growth of a movement: Principles agreed to by major professional associationsNCQA standards, measures, system of recognitionThe promise: Better health outcomes, reduced disparities; lower health care costA Vision of Beyond the Medical Home:Integrated Delivery Systems/Accountable Care

23、 OrganizationsVertically integrated, comprehensive servicesResponsible for total care of a populationUse of value-based payment (bundled or global payments) which:Rewards quality and outcomesAchieves savingsExamples: Kaiser, Mayo, Geisinger, IntermountainStrategies for Transformation: PCDC Performan

24、ce Improvement ProgramsMedical Home Recognition Assist providers to achieve NCQA recognition and transformation (also 2 programs below)Practice Redesign Improve access and efficiency by eliminating wait times-both for appointments and during the visitincreasing through-put (productivity), improving

25、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:Attracting and Retaining

26、 PatientsIncreasing RevenuePrimary Care Emergency PreparednessPerformance Improvement PCDC ApproachFocus on:System DesignImplementationMeasurable ResultsStaff Organized as Care TeamsBuilding Client CapabilitySustainabilityUse of:Change TeamsChange Concepts & TacticsCoaching and TrainingCollaborative

27、 LearningProject ManagementFrameworks for ImprovementModel for Improvement (IHI)Chronic Care Model (Ed Wagner)Medical Home ModelA. Practice RedesignThe Issues:Patient visits often average 2 to 3+ hours (for 15 minutes of actual face-time).Patients often wait 3-6 weeks for an appointment; instead go

28、to the ERNo shows run as high as 50-60%; providers overbook to make upOrganizations operate well below capacity (25-35%)Redesign process is complex, resource-intensive, challenging for self-implementationProgram Results:Trained 219 teamsNo show rates decrease by nearly 70% Appointment backlogs drop

29、from an average of 21 to 0-5 daysProviders able to hold 4-8 same-day appointments in daily scheduleCycle time reduced to an average of 51 minutes (50%+ reduction)Provider productivity increase of 33%Improved patient and staff satisfaction.B. Implementation and Meaningful Use of HITThe Issues:Difficu

30、lt, expensive, risky processOrganizations with little experience or internal capacity, few resourcesExcessive, vendor-generated information; little ability to evaluateThe Program: TA for all stages of HIT adoption (38 teams)HIT vendor selection and contracting (23 teams)Planning and readiness (11 te

31、ams)Internal capacity: team building, staff training, project managementDesign (workflow, decision support)BudgetingImplementation and go-live (6 teams)Effective use (Assure “meaningful use” compliance)Data reporting (Quality, compliance, panel management) (2 teams)Health information exchange (6 tea

32、ms)Remediation (1 team)The Challenge of the Next Five Years2 simultaneous, highly-interrelated, time-limited initiativesBoth improve care, provide financial incentivesNCQA medical home recognition: NYS Medicaid Incentive PoolFFS: $5.50/$11.25/$16.75 per visit for Levels 1/2/3Managed Care: $2/$4/$6 p

33、mpm for Levels 1/2/3Level I phased out after December 2012HIT meaningful use complianceMedicaid: Up to $63,750 over 6 yearsMedicare: Up to $48,000; penalties beginning in 2015Both are complex, expensive, a challenge for self-implementation Current focus on PCDC program development5. Lessons & Reflec

34、tions5. Reflections: The Nature of Organizational ChangeThe under-appreciation of implementationPeople know what needs to be changed. They lack knowledge of how to changeTransforming the model of primary care requires major, thorough-going organizational and cultural change. Myths:It can been done “

35、fast and cheap”Its a project. Once done, we can move on to other things.It can be delegated from the topThe importance of technical assistance, willingness to invest in the change processThe under-appreciation of everyday operationsPractice redesign, HIT as preconditions for clinical improvements, q

36、ualityReflections on Safety Net SettingsPrivate practiceStrong on continuity, access and efficiencyIsolation raises concerns about quality, coordinationSetting is simpler, change is easierSmall size, spare resources pose a challenge to implementing HIT, PCMH Community Health CentersContinuity, access, efficienc