1、 Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009National 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
2、 Development CorporationThursday,January 21,2010 Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 20091.Introduction:The Problems2.Health Care Reform:The Primary Care Agenda3.Primary Care Expansion4.Primary Care TransformationA.Practice Redesign B.Health Information Technology5.Le
3、ssons and ReflectionsOverview Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 20091.Introduction:The Problems Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Rising Cost and the Role of Chronic Illness The rising cost of health care is unsustainable Cost i
4、s driven by the rising rate of chronic illness.It:Is the single largest cause of morbidity and mortality Is the single largest driver of cost(accounts for 75%of all health expenses)Has the heaviest impact on low income communities Will grow more severe as population ages Chronic illness is overwhelm
5、ingly preventable or primary care manageable.Prevention and management require a robust model of primary care.Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Primary Care Today:Insufficient and Poorly Organized Primary care capacity is insufficient:60 million Americans lack a
6、ccess to primary care Half of primary care doctors plan to reduce or end their practices Only 20 percent of medical students plan to practice primary care U.S.is expected to need 46,000 primary care doctors by 2025 Most primary care is poorly organized and still practiced in an outdated mode.It is:R
7、eactive and episodic Subject to long waits and delays Uncoordinated Inefficient Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Study:US Lags Behind other Countries in Key Primary Care Indicators Commonwealth Fund study of 11 countries (November 2009)Australia,Canada,France,G
8、ermany,Italy,Netherlands,New Zealand,Norway,Sweden,UK,US US 10th out of 11 in use of Electronic Medical Records(46%-ahead of Canada)10th of 11 in use of care teams(ahead of France)Last in access to after-hours care Least likely to have financial incentives for clinical outcomes Excellent Healthcare
9、in Every Neighborhood.All rights reserved.PCDC 20092.Health Care ReformThe Primary Care Agenda Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Health Reform Will Drive the Need for Expanded Primary Care Capacity Expanded insurance coverage will put millions of new customers i
10、nto the healthcare market Physician shortages will increase by 25%and workload by 29%over the next 15 years.The Massachusetts experience:97%coverage Patients wait months for appointments 40%of family physicians are not accepting new patients Record use of ER for non-emergencies Excellent Healthcare
11、in Every Neighborhood.All rights reserved.PCDC 2009Rising 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 pr
12、imary care as the new paradigm.A new model 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)Excellent
13、 Healthcare in Every Neighborhood.All rights reserved.PCDC 2009PCDC:Offering Strategies for Primary Care Expansion and Transformation Non-profit organization founded in 1993 to address lack of primary care access in underserved communities Premier public-private partnership focused on needs of safet
14、y net providers-community health centers,hospitals,special needs providers Three areas of expertise Capital Financing Performance Improvement Policy Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 20093.PCDC:Strategies for Expanding Primary Care Expansion Excellent Healthcare in
15、Every Neighborhood.All rights reserved.PCDC 2009PCDC 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 leverage private investment Provide favorable-te
16、rm loans to catalyze construction of new,expanded and renovated sites,modernized facilities Provide:Technical assistance for facility development Provide strong oversight to ensure successful project completion and long-term sustainability Excellent Healthcare in Every Neighborhood.All rights reserv
17、ed.PCDC 2009ResultsTotal 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 mul
18、tipliersFacilities operating successfully,no defaultsPCDC Capital Projects(partial list)Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Joseph P.Addabbo Family Health Center Queens,NYBeforeAfter$9.4 million for 22,000 SF new facility;increased patient visits by 40%Excellent H
19、ealthcare in Every Neighborhood.All rights reserved.PCDC 2009Callen-Lorde Community Health Center ChelseaBeforeAfter$9.3 million for relocation&expansionIncreased patient visits from 8,000 to 48,000 annually Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Reflections on Capit
20、al 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 other initiatives(e.g.,transformation;policy)Technical assistance is cri
21、tical 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 reform Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 20094.PCDC:St
22、rategies for Transforming the Primary Care Model Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009The Need for TransformationOrigin:Initial focus on financial strength of borrowersNew realization:Poor work processes Cause much capacity to go unused Become important barrier to
23、access Result in inefficiency and waste Undermine financial strength Demoralize 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 Discover
24、y of the gap between what is possible and what is.Whats possible?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 home Excellent Healthcare in Every Neighborhood.All rights
25、reserved.PCDC 2009A Vision of Transformation:The Patient-Centered Medical Home The medical home concept:Continuity Well organized(efficient)practice Easy access:Same day appointments,24/7 telephone access,alternative access Responsibility for health outcomes Panel management Care coordination across
26、 settings Decision support Incorporation of evidence based practice(prevention,treatment,management)Patient/family engagement Formalization and the growth of a movement:Principles agreed to by major professional associations NCQA standards,measures,system of recognition The promise:Better health out
27、comes,reduced disparities;lower health care cost Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009A Vision of Beyond the Medical Home:Integrated Delivery Systems/Accountable Care Organizations Vertically integrated,comprehensive services Responsible for total care of a populat
28、ion Use of value-based payment(bundled or global payments)which:Rewards quality and outcomes Achieves savings Examples:Kaiser,Mayo,Geisinger,Intermountain Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Strategies for Transformation:PCDC Performance Improvement Programs1.Medi
29、cal Home Recognition Assist providers to achieve NCQA recognition and transformation(also 2 programs below)2.Practice Redesign Improve access and efficiency by eliminating wait times-both for appointments and during the visitincreasing through-put(productivity),improving patient and staff satisfacti
30、on and increasing revenues.3.HIT Implementation and Meaningful Use Adopt and integrate technology to improve quality,coordinate and manage care,engage patients and improve patient-provider communication.4.Other PCDC Performance Improvement Programs:Attracting and Retaining PatientsIncreasing Revenue
31、Primary Care Emergency Preparedness Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Performance Improvement PCDC Approach Focus on:System Design Implementation Measurable Results Staff Organized as Care Teams Building Client Capability Sustainability Use of:Change Teams Chang
32、e Concepts&Tactics Coaching and Training Collaborative Learning Project Management Frameworks for Improvement Model for Improvement (IHI)Chronic Care Model(Ed Wagner)Medical Home Model Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009A.Practice RedesignThe Issues:Patient visit
33、s often average 2 to 3+hours(for 15 minutes of actual face-time).Patients often wait 3-6 weeks for an appointment;instead go 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,challengin
34、g for self-implementationProgram Results:Trained 219 teamsNo show rates decrease by nearly 70%Appointment backlogs drop 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 productivit
35、y increase of 33%Improved patient and staff satisfaction.Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009B.Implementation and Meaningful Use of HITThe Issues:Difficult,expensive,risky processOrganizations with little experience or internal capacity,few resourcesExcessive,vend
36、or-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 teams)Internal capacity:team building,staff training,project managementDesign(workflow,decision support)BudgetingImpleme
37、ntation and go-live(6 teams)Effective use (Assure“meaningful use”compliance)Data reporting(Quality,compliance,panel management)(2 teams)Health information exchange(6 teams)Remediation(1 team)Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009The Challenge of the Next Five Years
38、2 simultaneous,highly-interrelated,time-limited initiatives Both improve care,provide financial incentives NCQA medical home recognition:NYS Medicaid Incentive Pool FFS:$5.50/$11.25/$16.75 per visit for Levels 1/2/3 Managed Care:$2/$4/$6 pmpm for Levels 1/2/3 Level I phased out after December 2012 H
39、IT meaningful use compliance Medicaid:Up to$63,750 over 6 years Medicare:Up to$48,000;penalties beginning in 2015 Both are complex,expensive,a challenge for self-implementation Current focus on PCDC program development Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 20095.Lessons
40、&Reflections Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 20095.Reflections:The Nature of Organizational ChangeThe under-appreciation of implementation People know what needs to be changed.They lack knowledge of how to change Transforming the model of primary care requires maj
41、or,thorough-going organizational and cultural change.Myths:It can been done“fast and cheap”Its a project.Once done,we can move on to other things.It can be delegated from the top The importance of technical assistance,willingness to invest in the change processThe under-appreciation of everyday oper
42、ations Practice redesign,HIT as preconditions for clinical improvements,quality Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Reflections on Safety Net SettingsPrivate practiceStrong on continuity,access and efficiencyIsolation raises concerns about quality,coordinationSett
43、ing is simpler,change is easierSmall size,spare resources pose a challenge to implementing HIT,PCMH Community Health CentersContinuity,access,efficiency not assuredFQHCs offer robust model,many PCMH functions,experience in quality improvementSpecial Needs ProvidersAlready offer a“care home,”instinct
44、ually understand medical homeHospital OPDsBroad scope of service available(specialties,ancillaries)Continuity,access,efficiency present challenge in teaching environmentPrimary care is not the institutional focus or priority Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009Ref
45、lections:PCDC as a Model for Expanding and Transforming Primary CareLeverages private investment for small investment of public resources;availability of capital(relative to expense)Produces measurable,sustainable outcomes,able to reach scale;builds lasting community infrastructure;delivers importan
46、t community development benefitsWorks across wide range of provider types(community health centers,hospitals,private practitioners)Is adaptable to localities,states,foundationsOffers excellent platform upon which to build additional programs and servicesValue of an organization dedicated solely to primary careBuilds a strong community of interest in the success of primary care.Excellent Healthcare in Every Neighborhood.All rights reserved.PCDC 2009ContactRonda KotelchuckExecutive DirectorPrimary Care Development CorporationPhone:(212)437-3917E-Mail:rkotelchuckpcdcny.orgWebsite:www.pcdcny.org
