Download The Commonwealth Fund 2011 International Health Policy

THE
COMMONWEALTH
FUND
Primary Care for 21st Century High
Performance Health Systems
Potential to Improve and Opportunities to Learn
HSRAANZ Conference, December 2011
Cathy Schoen, Senior Vice President
The Commonwealth Fund
www.commonwealthfund.org
2
Primary Care for 21st Century Health Care Systems
• Patient-Centered, High Performance Care Systems
– Goals: Accessible, High Quality (Outcomes/Health)
and Sustainable Costs
– Primary care teams and “medical homes” potential
• Insights from 2011 International Survey of adults with
serious acute or ongoing chronic disease
– Often shared concerns in diverse systems
– “Medical homes” make a difference
• Innovative models – U.S. examples
– Teams
– Information and new communication technology
• Opportunities to learn from country initiatives
Transforming Primary Care
Patient-centered teams and Care Systems
• Patients receive enhanced
access to primary care,
well coordinated by a team
• Patients actively engaged
(treatment decisions, care
at home)
• Teams use decisionsupport tools, assess
performance & receive
payment support
• Linked to care continuum –
care system; health focus
2020 Vision
Accessible
Patient Centered
Coordinated Care
Patient-Centered Care and Care Systems: Primary
Care Foundation Connected to Care System
Insights from Patient Experiences from 2011
International Survey in Eleven Countries
• Survey of “sicker” adults:
– Serious acute or ongoing chronic care conditions
– Recent hospital, surgery, serious illness, or
fair/poor health
• Eleven Countries:
– Australia, Canada, France, Germany, Netherlands,
New Zealand, Norway, Sweden, Switzerland, U.K.,
and United States
• Often shared experiences in diverse care systems
– Care coordination, safety, engaging patients
– Medical homes (accessible, know patients, help
coordinate care) make a positive difference
5
6
Cost-Related Access Problems in the Past Year
Percent because of
costs:
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Did not fill
prescription or
skipped doses
16
15
11
14
8
12
7
7
9
4
30
Had a medical
problem but
did not visit
doctor
17
7
10
12
7
18
8
6
11
7
29
Skipped test,
treatment, or
follow-up
19
7
9
13
8
15
7
4
11
4
31
Yes to at least
one of the
above
30
20
19
22
15
26 14
11
18
11
42
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
7
Out-of-Pocket Spending and Problems Paying
Medical Bills in Past Year
More than US$1,000
OOP Costs
Percent
Serious Problems Paying or
Unable to Pay Medical Bills
60
50
35 36
40
30
39
27
24
20
11 12 13
10
1
5 6
16
1
7 8 8 8
6
5
4
0
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
11
14
Access to Doctor or Nurse Last Time Sick
or Needed Care
Same- or next-day
appointment
Waited six days
or more
Percent
100
75
50
25
79 79 75 75
70
63 59 59 59
51 50
14 16
12
10
8
2 4 5
0
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
22 23 23
8
9
After-Hours Care and Emergency Room Use
Difficulty Getting After-Hours
Care Without Going to the ER
Used ER in Past Two Years
Percent
100
75
52 55 55 56
50
34 35
25 21
26
40 40
63
58
31 32 33
39 40 40
47 48 49 50
0
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
10
Experienced Coordination Gaps in Past Two Years
Percent
80
60
53
40
20
30
20
36
37
39
40
AUS
NETH
SWE
CAN
42
43
US
NOR
56
23
0
UK
SWIZ
NZ
FR
GER
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to
share important information with each other, specialist did not have information about medical history, and/or regular doctor not
informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Gaps in Hospital or Surgery Discharge Planning
in Past Two Years
Percent
100
80
60
40
26
29
UK
US
48
50
51
SWIZ
CAN
NZ
55
61
66
67
71
73
NOR
FR
20
0
AUS
GER
NETH SWE
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know
who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements
made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
11
Patient Reported Medical, Medication or Lab-Test
Error in Past Two Years
Percent
50
40
30
20
10
8
9
UK
SWIZ
13
16
19
20
20
21
22
22
AUS
NETH
SWE
CAN
NZ
US
25
0
FR
GER
*Medical
NOR
mistake, or wrong drug/wrong dose, incorrect lab test results, delay in hearing about
abnormal lab test.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
12
13
Patient-Doctor Relationship and Communication
Percent reported
regular doctor
always/often:
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
Spends enough
time with you
85
77
82
86
87
87
71
70
88
87 81
Encourages you
to ask questions
and explains
things in a way
that is easy to
understand
69
59
53
64
54
67
31
41
77
77 71
Always/often to
both
66
54
50
61
52
65
27
37
73
72 65
Base: Has a regular doctor/place of care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
US
Patient Engagement in Care Management
for Chronic Condition
Percent reported
professional in past
year has:
Discussed your
main goals/
priorities
Helped make
treatment plan
you could carry
out in daily life
Given clear
instructions on
symptoms and
when to seek
care
Yes to all three
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
63
67
42
59
67
62
51
36
81
78 76
61
63
53
49
52
58
41
40
74
80 71
66
66
56
64
64
63
44
49
84
80 75
48
49
30
41
42
45
23
22
67
69 58
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
14
US
15
Primary Care “Medical Homes”
Accessible, Knows Medical History, Helps
Coordinate care
16
Patients with a Regular Doctor vs. Medical Home
Has a regular doctor or place of care
Has a medical home
Percent
100
80
99
99
99
99
99
97
91
74
70
100
97
96
95
65
56
60
53
52
51
49
48
48
40
33
20
0
UK
SWIZ
NZ
US
NOR
FR
AUS
CAN
GER
NETH SWE
Patients with a medical home have a regular practice who is accessible, knows
them, and helps coordinate their care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
17
Patient-Doctor Relationship and Communication,
by Medical Home
Percent reporting positive patient-doctor
relationship and communication*
Medical home
100
80
60
79
52
40
80
79
65
59
55
50
38
82
76
72
70
No medical home
40
40
51
45
54
41
36
28
18
20
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
* Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way
that is easy to understand.
Base: Has a regular doctor/place of care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
18
Patient Engagement in Care Management
for Chronic Condition, by Medical Home
Percent reporting positive patient engagement
in managing chronic condition*
100
Medical home
No medical home
80
60
59
56
54
51
47
40
76
73
38
38
34
33
24
29
67
51
45
32
27 29
20
46
16
15
NOR
SWE
0
AUS
CAN
FR
GER
NETH
NZ
SWIZ
UK
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make
treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
US
19
Experienced Coordination Gaps in Past Two Years,
by Medical Home
Percent*
100
Medical home
No medical home
80
57
60
49 49
53
59
42
41
40
31
41
32
30
54
51
36
42
32
25
20
20
33 33
30
15
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to
share important information with each other, specialist did not have information about medical history, and/or regular doctor not
informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Hospital or Surgery Discharge Planning Gap in Past Two
Years, by Medical Home
Percent*
Medical home
100
82
80
78
74
66
63
57
60
49
6063
68
59
43
No medical home
64
70
67
59
42
53
46
41
40
17
20
19
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know
who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements
made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
20
Medical, Medication, or Lab Test Errors in Past Two Years,
by Medical Home
Percent*
Medical home
40
30
29
27
23
23
18
20
15
15
15 15
No medical home
29
29
22
22
19
16
16
17
15
14
10
10
6
6
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
US
21
22
Rated Quality of Care in Past Year as “Excellent" or
“Very Good,” by Medical Home
Percent
Medical home
100
80
88
83
79
72
77
72
65
60
No medical home
62
59
56
46
49
44
38
40
57
60
44
35
43
34
27
26
GER
NETH
20
0
AUS
CAN
FR
NZ
NOR
SWE
SWIZ
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
US
23
Patient-Centered, Coordinated Primary Care Medical
Homes as Part of Systems Approach
• Systems approach: Access, Quality, Efficiency
• Primary care medical or “health” homes
– Timely access to care: multiple points of access
– Patient engagement in care
– Information systems: quality & coordination
– Routine feedback of patient and clinical outcomes
– Coordinated care, creative use of teams
– Incentives and system support to improve/innovate
Approach to redesigning primary care
– Part of “system” of care the aims to organize care
around patients and focus on outcomes
U.S. Multiple Models of Medical Homes and Teams
Community Care of North Carolina
Examples of Cost and Quality Outcomes
from Primary Care Medical Home Interventions
Geisinger Health System (Pennsylvania)
• 18 percent reduction in all-cause hospital admissions; 36% lower readmissions
• 7 percent total medical cost savings
Mass General High-Cost Medicare Chronic Care Demo (Massachusetts)
• 20 percent lower hospital admissions; 25% lower ED uses
• Mortality decline: 16 percent compared to 20% in control group
• 7% net savings annual
Guided Care - Geriatric Patients (Baltimore, Maryland)
• 24 percent reduction in total hospital inpatient days; 15% fewer ER visits
• 37 percent decrease in skilled nursing facility days
• Annual net Medicare savings of $1,364 per patient
Group Health Cooperative of Puget Sound (Seattle, Washington)
• 29 percent reduction in ER visits; 11% reduction ambulatory sensitive admissions
Health Partners (Minnesota)
• 29% decrease ED visits; 24% decrease hospital admissions
Intermountain Healthcare (Utah)
• Lower mortality; 10% relative reduction in hospitalization
• Highest $ savings for high-risk patients
Pennsylvania: Geisinger Medical “Navigator” Home Sites and
Hospital Admissions/Readmissions
Hospital admissions per 1,000 Medicare patients
Medical Home
Non-Medical Home
Readmission Rates for All
Medical Home Sites
25
20
450
425
400
375
350
325
300
19.5
15.9
15
10
5
0
CY 2006
CY 2007
CY 2006
CY 2007
As of Q4-2008*: • 18% reduction in hospital admissions
• 36% reduction in hospital readmissions
• 7% total medical cost savings
Source: Geisinger Health System, 2009. *Results reported in: R. Gilfillan et al, “Value and the Medical Home: Effects
of Transformed Primary Care,” The American Journal of Managed Care, 16(8) 2010: 607-614.
27
Vermont: Shared Resources Community Teams
 A foundation of medical homes and
Hospital
s
Medical
Home
Specialty Care & Disease
Management Programs
Community Health Team
Nurse Coordinator
Social Workers
Nutrition Specialists
Community Health
Workers
MCAID Care
Coordinators
Public Health Specialist
Social, Economic, &
Community
Services
Mental Health &
Substance Abuse
Programs
Healthier Living
Workshops
Public Health
Programs & Services
Health IT Framework
Evaluation Framework
Medical
Home
Medical
Home
Medical
Home
community health teams that can
support coordinated care and
linkages with a broad range of
services
 Multi Insurer Payment Reform that
supports a foundation of medical
homes and community health teams
 A health information infrastructure
that includes EMRs, hospital data
sources, a health information
exchange network, and a
centralized registry
 An evaluation infrastructure that
uses routinely collected data to
support services, guide quality
improvement, and determine
program impact
THE
COMMONWEALTH
FUND
International Innovations in Access “After-Hours”
Early Morning, Nights and Weekends
28
• Denmark
– County wide physician cooperatives with phone and visit
center
– Computer connections to medical records
– Reduce physician workload
• Netherlands
– 2000/2003: Cooperatives evening to 8 AM and weekends;
Nurse led with physician available
– House calls for emergencies
– Reduce physician workload and use of emergency rooms
• United Kingdom
– Some cooperatives developing; walk-in centers
– 24 Hour Help Line: NHS Direct
Source: Grol et al., “After-Hours Care in the U.K., Denmark, and the Netherlands: New Models,” Health
Affairs, Nov./Dec. 2006; Schoen et al., “On the Front Lines of Care,” Health Affairs Nov. 2, 2006.
THE
COMMONWEALTH
FUND
29
24/7 Access: Dutch GP After-Hours Cooperatives
• Since the 2000s, 127 GP
cooperatives; cover more than
90% of the population
• Access to after-hour primary
care through single telephone
number
• Community physicians rotate;
nurse staffed – phone and visit
• Home visits with medically
trained car drivers in fully
equipped cars (e.g. O2, infusion
drip, automatic defibrillation
equipment)
• Electronic health records;
communication to regular GP
Source: J. Burgers, UMC St Radboud, Providing After-hours Primary Care in the Netherlands presentation at
The Commonwealth Fund Harkness Alumni Policy Forum, May 20-22, 2011.
THE
COMMONWEALTH
FUND
Visiting Nurse Service New York Health Plans
30
Patient-Centered Care Teams for High-Cost Chronically Ill Medicare
and Medicaid – Special Needs and Long Term Care
•
•
•
•
•
Interdisciplinary teams; home and community care; transition care
Care and assist with navigating complex health care systems
Patient-centered: targets and customizes interventions
Strong health information technology and EHR; Support team
Positive results
• Improved primary care access; high quality and patient ratings
• Reduce hospital admissions, readmissions, ER use (17 to 27%)
• Links primary, specialist and long term care
• Patient and family preferences
THE
COMMONWEALTH
FUND
Summary of presentation by Carol Raphael, Pres and CEO, NY Visiting Nurse Assn., 6/2011
31
•ED visits reduced 67%
•Hospital admissions reduced 84%
•Lost school days reduced 41%
•Missed work days
(Parents/caregivers) reduced 55%
Home visits • Medication education •
Asthma management tools for
patients • Understanding triggers and
reducing triggers in the home •
Connecting families to community
resources
•Recipient of U.S. Environmental
Protection Agency’s 2010 National
Environmental Leadership Award in
Asthma Management
THE
COMMONWEALTH
FUND
Source:
http://www.childrenshospital.org/clinicalservices/Site1951/mainpageS1951P0.html
32
Alaska Dental Health Aide Program Improves
Access to Oral Health Care
Dental Health Aide Therapist Program,
Class of 2010
Student in clinic
•
Began in 2003; first of its kind in the
United States
•
High unmet need, particularly in rural
communities
– Dentist shortages
– High rates of oral diseases
•
Dental therapists provide education,
preventive services, and basic
treatment in regional hub clinics and
remote village clinics
•
Focuses on reaching children,
pregnant women, and other high-risk
residents
•
Evaluation: providing safe,
competent, appropriate care
Source: Alaska Dental Health Aide Therapist Initiative, Alaska Native Tribal Health Consortium.
http://www.anthc.org/chs/chap/dhs/
THE
COMMONWEALTH
FUND
33
Creative Use of Information
and Communication Technology
THE
COMMONWEALTH
FUND
Boston Mass. General Hospital: Care Redesign
T. Ferris, G. Meyer, P. Slavin presentation to Commonwealth Fund 4-2011
Longitudinal Care
Primary Care
Episodic Care
Specialty Care
Patient portal/physician portal
Access to care
Hospital Care
Hospital Access Center
Extended office hours
Non face-to-face visits
Reduced admits/1000
Defined process standards in priority conditions
(multidisciplinary teams)
High risk care
management
Shared decision making
100% preventive services
Appropriateness
Design of care
Re-admissions
Hand-off standards
Continuity visit
EHR with decision support and order entry
Incentive programs
Variance reporting/performance dashboards
Measurement
PMPM, HCI, ACSH,
Pharmacy
Clinical and Patient
Reported Outcomes
LOS, CMAD, HACs,
Re-Admits
Hospital: Use of IT to Predict Risk and Marshal
Resources, Including Transition Care/Discharge
70
Derivation Samples
Validation Samples
60
51.65
45.68
50
40
26.93 26.0
30
20
14.27
16.08
17.94
19.98
12.22
8.77
10
0
Very Low
Low
Intermediate
High
Very High
Predicted Readmission Risk Category
Parkland, Texas: An EMR model to predict 30-day readmission for heart failure
using SES risk and clinical risk. Model includes: systolic and diastolic blood pressure, pulse, temperature,
pH, BNP, PT/ INR, glucose, CK-MB, troponin, wbc, pCO2, BUN, sodium, creatinine, CK, bilirubin, albumin, age, history of
depression, single, male, no. of home address changes, medicare, high risk census tract, cocaine use, missed clinic visit,
used pharmacy, prior inpatient admissions, ED presentation time. C-statistic: Derivation: 0.73; Validation 0.69
Source: Ruben Amarasingham, MD, Parkland Health and Hospital System, Presentation to Commonwealth
Fund on May 12, 2010, “Harnessing Electronic Medical Record Data to Reduce Readmissions.”
Telehealth & Electronic Communication
• North Dakota Telepharmacy Project –
Reaching over 40,000 rural residents
• E-consults and referrals
― San Francisco General
Hospital
― The Mayo Clinic
― Group Health
• Veteran’s Health Administration–
Scaling up Telehealth Services
Tele-Health and Electronic Communication:
37
Enhanced Access and Care Teams
• Veteran’s Administration: serving 31,000 frail at home; aim to
serve 92,000 by 2012
– High patient ratings; Link to care teams – home visits
– 40 percent reduction in “bed-days” by 2010 compared to start
• U.Tennessee Memphis: Remote specialist consultations with
patients, local clinicians. Center serves 3 state region
– Reduce heart failure admission + readmissions by 80%
– “real time” diabetic retinopathy (digital) report results
• Primary care to Specialist e-consultations and referral
– Mayo, SF General, Group Health Puget Sound
• Kaiser : Web access, e-visits/consultation - outreach and booking
• Henry Ford Detroit: Kiosks in churches, communities
THE
COMMONWEALTH
FUND
38
Keys to Rapid Progress
Teams and Care System Redesign
Information
Systems
Payment Reform: Value
THE
COMMONWEALTH
FUND
39
Primary Care Redesign
• Primary Care Teams, including Long Term Care
– Expanded set of skills; new work roles
– Nurse and medical assistants new roles and skills
– Education and training
– Everyone “working to top of skill set”; learning
• Shared resources include teams and information systems
– Primary care and specialist linked through information
systems: opportunities to learn, coach
– Home care and long-term care nursing teams work with
multiple practices
• Scope of practice, delegation to enable teamwork
• Prevention and population health: community health
outreach
THE
COMMONWEALTH
FUND
Primary Care, Health Care System
and Population Health
• Whole system view
– Health and value gains if we use resources more
creatively and productively
– Primary care, teams, information, shared services,
population health – beyond “facilities”
• Focus on key areas
– Transforming primary care, teams and care
systems
– Creative use of electronic health information
systems and technology
– Shared resources
– Aligning Payment and Regulations with Value
41
Primary Care Innovation: Rich Opportunities
to Learn from International Initiatives
Focused on Achieving Core Health Care System Goals
Better Population
Health
Better Care
Experiences
Institute for Healthcare Improvement (IHI) Triple Aim
Slow or Reduce per
Person Costs
THE
COMMONWEALTH
FUND
For More Information Visit the Fund’s website at
www.commonwealthfund.org
For survey results: C. Schoen, R. Osborn et al. “New 2011 Survey of
Patients with Complex Needs Finds that Care Is Often Poorly
Coordinated,” Health Affairs, Nov. 9, 2011 Web first
42
THE
COMMONWEALTH
FUND
43
2011 Survey Profile of Sicker Adults
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Age 50 or older
57
50
54
60
57
54
60
58
63
62
56
Has 2+ chronic
conditions (out
of 8)
44
41
34
42
34
34
35
26
37
45
53
54
43
37
37
51
36
43
37
40
39
50
46
46
38
48
35
54
46
48
41
40
38
Saw 4+
doctors
32
21
23
36
24
26
19
23
6
16
21
Taking 4+
prescription
medications
regularly
28
30
26
24
31
27
29
30
24
35
37
Percent
Health care use
in past 2 years:
Hospitalized
Surgery
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.