2012 Medical Home Summit Highlights

Key Take Aways from the 2012 National Medical Home Summit February 27-29, 2012 in Philadelphia.

by Steve Wilkins, MPH

I had the opportunity to attend and speak at the Fourth National Medical Home Summit in Philadelphia on February 27-29,2012.   I have summarized here highlights from the three-day event.

Highlights from the Day 1 Plenary

Ed Wagner, MD, developer of the Chronic Care Model, provided an in-depth review of the CCM over the last 10 years.  He reiterated the five strategies that are working best in busy primary care practices: greater use of non-physician team members, planned encounters and follow-up, modern self-management support, care management for high risk patients, and population or panel management using registries. Dr. Wagner offered up a great way of distinguishing good care from– usual care.  Good care maximizes the effectiveness of every interaction between the patient and the provider team…usual care not so much.

Peggy O’Kane, NCQA, presented an update on 2011 PCMH NCQA standards as well as NCQA’s new ACO accreditation program. I am still wondering when NCQA, URAC, Joint Commission, etc. will beef up requirements for patient-centered communications because you can’t “get there” without it.

Who knew that WebMD was involved in lifestyle management and chronic condition consulting and management?  Scott Heimes from WebMD provided an overview to their lifestyle management and chronic care management services.  WebMD’s focus is on digital coaching (Digital Health Assistant) – emulating a human being going through coaching experience, biometric measurement, mobile, social media, and video conferencing.  

Highlights from the Day 2 Plenary

Bev Johnson, Summit Co-chair, Institute for Patient- and Family-Centered Care, opened Day 2 with a call for doing it right with respect to redesigning primary care. She reiterated the necessity to partner with patients and families in this endeavor.

There’s nothing like “seeing” what patient-centered communication looks like in action which is why I really appreciated the presentation by Laura Makaroff, DO and Pat Schmidlapp, a patient and current member of Health-TeamWorks Patient Advisory Committee.  As part of their presentation they simulated a doctor-patient visit in which they demonstrated a key communication tactic – how to ask for the patient’s perspective.  They talked about the importance of capturing the patient’s perspective from both Pat’s and Laura’s viewpoints.

If you are looking for a well conceived “operating system” for creating great patient and family experiences in your PCMH, and other services, check out Michael Celender’s presentation on what they are doing at the Innovation Center of University of Pittsburg Medical Center. The three keys to UPMC’s approach include: 1) View all care as an experience through the eyes of the patient and family, 2) need to engage patients and families – goal is experience-base co-design of care – UPMC uses patient advisory councils, Voice of Patients, , and 3) adoption and spread of this  to any patient care experience.  I really liked the “shadowing” component in which care givers, patients, and families allow UPMC staff to identify and map of key touch point maps and flow maps for creating great patient experiences.

There is a lot of interest in ways to integrate patients into the PCMH/primary care redesign process.  Dr. Karen Jones, Kathy Hutcheson, and patient partner Dick Simpson talked about the methods used by WellSpan Health.  They have formalized the patient’s role by creating job descriptions, recruitment strategies, and a four-hour training program for the two patients recruited for each PCMH site.  Dick Simpson talked about his positive experiences over the course of going through the training and becoming an active member of Wellspan’s initiative.

Patient engagement has been cited as the Achilles heel of PCMH.  Steve Wilkins (me), a researcher and blogger, talked about how the typical office visit medical exam is not designed to engage patients…and that poor quality of physician-patient communication may serve to disengage otherwise engaged patients.   I presented a research method, called conversation analysis, which evaluates physician’s patient communication skills.  Using audio recordings of patient-physician visits, analysts evaluate what physicians say to patients, how they say it, as well as the patient’s response.  Targeted communications interventions can then be targeted at individual physicians based upon the evaluation.

Highlights from the Day 3 Plenary

Since managing ambulatory sensitive conditions is an important aim of PCMH, I was interested in Dr. Renee Turchi’s experience with managing pediatric asthmatics in Pennsylvania’s Pediatric Medical Home practices.  In her work, she discovered that the greatest decline in ER use for asthmatics was noted not among the most severe asthmatics … but rather among the moderately severe groups.  Renee suggested that the medical home could well prevent all ER visits among this population leading to significant savings.

A compelling case was made by Lisa Bielamowicz, MD from the Advisory Board as to why hospitals should take a much more active role in supporting PCMH development by their primary care physicians. Market forces, particularly the changing case mix (decline of profitable surgical case and growth in less profitable medical cases) will force hospitals to do a better job of managing the medical cases outside the hospital. Yes, medical homes will cut inpatient volume meaning hospitals will need to focus on alternatives like the medical home and value-based care (ACOs).   This is a must see presentation for any hospital or hospital-affiliated PCMH.

Some Highlights from the Mini Summits

Are you familiar with the notion of a “compact” or agreement in PCMH?  Well I wasn’t and that’s why I found the presentations by Dr. Hammond and Dr. Lammert on the subject of PCMH-Hospital compacts to be very interesting.  The basic premise here is that some portion of the medical errors associated with patient handoffs post hospital discharge can be prevented by addressing the points in the process where problems are most likely to occur.  Dr. Hammond in particular presents a simple, logical approach for developing PCMH-Specialist-Hospital compacts which spell out the roles and expectations of  all the parties in the  “medical neighborhood.”

I love the point made by James Rose, Patient Engagement Systems, regarding the marketing hype surrounding the concept of patient engagement.  Rose correctly noted that patient engagement is more about the message you convey than the media used to convey the message.  Too often providers incorrectly equate web portals, in-office kiosks, and even printed health information with patient engagement.  What engages patients (or not) are the messages conveyed by these different media.  Often a simple verbal exchange between physician and patient can do more to engage patients in their own health than the most expensive web portal.  What’s your message?

Summary

This is a good conference for both newcomers to PCMH as well as veterans. I look forward to future conferences where I hope to see more consolidation of “learning” on the nuts and bolts of PCMH.   PCMH is no longer an experiment where everyone needs to feel compelled to reinvent the wheel “because our practice is different.    We know what works…now we just need to execute.  I also look forward to what I see as PCMH Version 2.0, where we will start to hear more about integrating patient-centeredness into the culture and practice of PCMH.   There is obviously not enough space to summarize every presentation, and these are just my thoughts.  Go browse for yourself in the web archive where you can see a two-minute preview of each presentation at www.MedicalHomeSummitPortal.com.

Steve Wilkins, MPH, is the Founder and Principal of Smart Health Messaging and the author of Mind the Gap, a blog about physician-patient communication.  He may be reached at stwilkins@gmail.com or on the web at www.healthecommunications.wordpress.com.

 Key Take Aways from the 2011 Medical Home Summit West

by Steve Wilkins, MPH

Together with Pat Salber, MD (www.thedoctorweighsin.com), I was Tweeting from the Medical Home Summit West, which was held September 20-22, 2011 in San Francisco.  The conference was rich in lessons learned and key take aways.

These are my impressions.

The Case for the Medical Home

Terry McGeeny, MD, TransforMED opened the Summit with an excellent overview of the state of Patient Centered Medical Homes (PCMH) development in the U.S..  McGeeny identified four criteria for PCMH success based upon TransforMED’s experience: 1) teamwork (after all PCMH has to be a team effort),   2) leadership (physicians must lead practice redesign and the team), 3) change management (physicians after all are change adverse), and 4) communication (among team members and with patients). Research shared by Steve Shortell, PhD supported the case for McGeeny’s success criteria.

The Need for Team Care in the Medical Home

Lots of reasons were given for why PCMH makes sense – it’s the right thing to do, to improve quality of care and patient outcomes, to improve patient satisfaction as well as increased reimbursement.  Perhaps the most important reason however was the shortage of primary care physicians.   Thomas Bodenheimer, MD, said that even with today’s increase in the number of physicians going into primary care, market demand will far outrun the supply of primary care physicians.

The answer according to just about every speaker is “team care,” with teams consisting of medical assistants, nurses, care coordinators, PAs and physicians.  Bodenheimer coined the term “teamlets” and recommended that PCMH teams consist of no more that 3 people. By implication, everyone on the team becomes a kind of care ccordinator for different aspects of the patient’s care.  Anything larger than that leads to more frequent inter-provider miscommunications.   More importantly, it is impossible for patients to develop a “trusting” relationship with teams of 4 or more providers.  From my standpoint, the jury is still out on whether patients want a relationship anyone other than the physician.  I know I don’t.

From a productivity stand point, the logic given for team care is pretty clear.  50% to 70% of what primary care physicians routinely do in office-based practices is below their pay and education grade and can be done by someone else. Similarly, it doesn’t take a nurse to room a patient or take their BP.  MAs can do this.

Panel Size in the Medical Home

Joseph E. Scherger, MD, (Eisenhower Medical Center), Carol Cordy, MD (Swedish), Alicia Eng of Group Health and others agreed that 1,800 patients represented the ideal panel size for a primary care physician in the PCMH model.  Of these, the MA may manage (referred to as a “touch”) a certain number of patients (healthy), the nurse/PA may manage certain patients (less healthy-stable chronic conditions) and the physician would manage only the sickest patients – those with unstable chronic conditions.  In such a model, the physician’s actual number of “patient touches” would be fewer, but longer, more productive, and more satisfying for both patient and physician.  

Medical Homes Are Not Just for Large Integrated Systems

Presentations by John Blair, MD, of Tactonic IPA and Nancy Gratz of Lehigh Valley Health Network challenge the perception that primary care redesign can only be done by large integrated health systems.  By applying thoughtful, facilitated chance management techniques, sharing learning, and by getting everyone involved (sometimes even the patient!!) real change over time is possible.  To quote McGeeny, “individual practices can provide the same higher quality at lower cost as published data from large integrated systems.”

Involving Patients and Their Families in the Medical Home

Mary Minniti, PeaceHealth, reminded us that “patients are the experts…and that they have information you need to hear and act on.”  PeaceHealth appears to have taken a leadership role in integrating patients and their families into the primary care redesign process with the use of Patient and Family Advisory Councils.  Surprisingly I can’t recall hearing the term “patient-centered” used anywhere else in the Summit which is concerning.  After all, is this all supposed to be about the patient rather than the provider?

External Recognition/Accreditation Programs

There were some very interesting discussions about external PCMH recognition programs like NCQA.  There is the very real risk that primary care practices simply “check off the boxes” on such accreditation programs in order to gain recognition.  Bodenheimer referenced instances where health systems actually were defunding PCMH initiatives after they achieved PCMH recognition.   Sounds like NCQA and others need to identify and start measuring PCMH criteria that really will make a long term difference.  After all, we in health care tend to only manage what we measure.  One recommendation I have is that accreditation groups start drilling down into the quality and effectiveness of physicians-patient communication…and no HCHAPS is not the answer – it is way too global and not actionable in any meaningful way.  In my work with providers I am exploring the use of conversation and interactional analytical techniques as a way of getting at this issue.

Accountable Care Organizations

I found Shortell’s “Top 10 Mistakes Fledgling ACOs Will Make” very insightful.  The top 3 mistakes alone are huge:

1. Overestimating ability to manage risk
2. Overestimating ability to implement Electronic Medical Records
3. Overestimate ability to collect, analyze and report performance measures

Other Interesting Take Aways

Wayne Pam, MD, Santa Clara Valley IPA, reminds us of the need to think creatively about our attempts at primary care redesign.  Based upon the interesting work of Stanford’s B.J. Fogg, Pam talked about a simple, high value pharmacy intervention his IPA recently implemented for integrating the pharmacist into the hospital discharge care transition process.

Martin Lieberman, DDS, was a bit of a refreshing surprise in that he talked about building a room in the medical home for Dental Care.  He gave several interesting examples documenting how dentists are often the first to detect signs of medical conditions like inflammation and heart disease.   Andrea M. Auxier, PhD similarly made a compelling case for including behavioral care in the medical home as well.

Not surprisingly, there was lots of discussions on health information technologies like registries, EMRs, PHRs, and health information exchanges as they relate to PCMH.   Group Practice Forum’s  Amber Winkler presented on HIT in the PCMH.

Despite the efforts of TransforMED and the Patient Centered Primary Care Collaborative (PCPCC), the PCMH movement is still very much a “cottage industry” with so many primary care physicians, IPAs and others each “on a similar journey” yet doing their own thing. Beverley Johnson, Institute for Patient- and Family-Centered Care, summarized evolving best practices for PCMH development, but my overall impression is that everybody is wasting time reinventing the wheel all across the US.

Missing from the PCMH discussion are primary care providers or payers from California.  California providers are perhaps guilty of thinking that their already is a medical home and that their physician-hospital partners are already ACOs. Maybe it’s their experience with capitation which has lead to a kind of smugness about PCMH and ACOs.  Maybe they have figured out how to efficiently deliver primary care, but as a patient living in California, with some exceptions, I don’t think California physicians, know much about practicing patient-centered care.

My Favorite Quote:

If you keep doing what you are doing, the same way you have always done it, you going to get the same results you have always gotten.

Len Fromer, MD, Group Practice Forum.

Final Thoughts

One of the more serious threats to the ability of PCMH to effect long term improvement in primary care delivery is the tendency for some primary care practices (or their sponsors?) to just “go through the motions” with respect to PCMH recognition.  In other words, PCMH is about more than implementing medical records, hiring a care coordinator, managing chronic disease, and improving a handful of quality measures.  It’s about patients and their ability to have access to high quality providers that take the time to get to know them, including their needs want and concerns, and who will collaborate with them through times of sickness and health.

Patient-Centered Care Begins With High Quality Doctor-Patient Communications

PCMH practices and their sponsors need to begin focusing on improving the quality of the dialogue between physicians and patients, e.g., patient-centered communications. After all, trust and excellent communications skills are the foundation for strong physician-patient relationships without which PCMH will not be possible.

Do Medical Home Physicians Really Communicate Any Better With Patients?

Steve Wilkins, MPH is a Thought Leader in physician-patient communications research and solutions and is the author of the blog Mind the Gap and contributor to Disease Management & the Medical Home, Chapter 3, Disease Management and Wellness in the Post-Reform Era, Published by AIS 2011.  

Steve is also the Founder of Smart Health Messaging, a provider of tailored communications solutions which enhance the typical office visit experience for doctors and patients while improving patient engagement, self-care, outcomes, and satisfaction.  He can be reached at swilkins@smarthealthmessaging.com or via his web sites at www.healthecommunications.wordpress.com and www.smarthealthmessaging.com.