UPMC Health PlanPartners in Excellence™

Patient-Centered Medical Home: An Integrated Approach with Results

Cynthia Napier Rosenberg, M.D.Senior Medical Director

Network Management and Provider RelationsUPMC Health Plan

Three Things Who we are

UPMC Health Plan Patient-Centered Medical Home Initiative:

Overview

Results Quality Cost Satisfaction

How we got there What Matters Access2 Copying, citing, quoting, or distributing without written permission of UPMC Health Plan is prohibited.

Where We Are

3 Copying, citing, quoting, or distributing without written permission of UPMC Health Plan is prohibited.

Who We AreUPMC

Hospital and Community

ServicesPhysician Services

Insurance Services

International and Commercial

Services

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Network Map

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UPMC Health Plan Overview More than 1.4 million members Integrated products, including:

Group Health Commercial Medicare (including SNP) Medicaid CHIP Wellness only Community Care

Employee Assistance Program (EAP) Claims Management Services

Workers’ Compensation Short-term Disability

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Integrated Care and Business Solutions

MyHealthLifestyleWellness

Askesis

UPMC Insurance Services Division

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UPMC Health PlanPatient-Centered Medical Home

Overview Made a strategic decision to organize

entire network operations and approach around principles of Patient-Centered Medical Home (PCMH)

Met with over 450 primary care practices serving adult members to assess each practice based on PCMH principles

Engaged a pilot group of four practices (approximately 8,300 members and 20 physicians) to work on an intensive, integrated PCMH approach.

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Spring, 2008 - Present Phase I PCMH

Six practice sites with 8300 members Phase II PCMH

Six additional practice sites with 14,600 members Phase III PCMH

105 additional practice sites with 62,000 members

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Spring, 2008 - Present

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Results: Quality Partners in Excellence: PCMH Phase 1

Other Network

Baseline Year 1 % ∆ Baseline Year 1 % ∆

Diabetes Denominator 877 796 -9.2% 9875 10,942 6.2%

LDL Test 49.9% 70.4% 40.9% 42.3% 46.9% 10.9%

A1C 79.7% 84.9% 6.6% 78.7% 79.3% 0.8%

Nephropathy 73.2% 82.5% 12.8% 76.0% 75.4% -0.7%

Eye Exam 75.6% 80.2% 6.0% 69.8% 71.7% 2.7%

Diabetes Completeness

33.2% 58.8% 77.2% 26.5% 30.3% 14.1%** NOTE: Baseline date is 6/2008. Year One date is 6/2009

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Results: Cost

Time Period Total Med and Pharm

Pharmacy Total

Total Medical

All Other Medical

Partners in Excellence: PCMH Phase 1

5.73% 7.60% 5.24% 0.53%

Other Network 9.83% 9.41% 9.93% 8.58%

Pre-Post Comparison (Baseline Year to Year One)

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Results: Efficiencies (Cost meets Quality) Middle-aged male with multiple chronic medical

conditions, including Diabetes, CAD, CHF, HTN, Peptic Ulcer Disease, Stroke, BPH, Urinary Retention, Neurogenic Bladder, Liver Disease, Hyperlipidemia, Sleep Apnea

Seven admissions in seven months ($30,000.00) PCMH Care Manager met with member, facilitated

appointments for durable medical equipment and home health services, engages mobile outreach representative, maintained frequent telephone contact with home health services and with member

No hospitalizations or ED visits in following two months Member compliant with outpatient office visits and

medications

Results: Satisfaction Physician

Independent and employed physicians, University of Pittsburgh School of Medicine faculty, residents

Over 80% would personally recommend program to another physician

Member Testimonials Member with newly-diagnosed symptomatic

hypertension. Placed on medication by PCMH physician.

Educational materials, contacted by PCMH office-based care manager. Follow-up both by phone and in-person over next several months.

“I would encourage anyone with health concerns to take advantage of the programs the Health Plan offers. The services are priceless.”

How We Got There Culture Change within and without organization:

An Integrated Systemic Payer-Provider Team Approach

Clear Mission: Work in an Integrated Fashion to put the tools and services of the Health Plan in the hands of the PCMH Provider

Expectation: Payer-Provider Team (two-way street)

Clear Goals: To Improve Health care, enhance patient and provider satisfaction, and control cost

Leadership Engagement of Everyone Involved in the

Program Engagement of Physician Community

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ACCESSRole of UPMC Health Plan: Supportive Services, Data,

Infrastructure

Infrastructure Lining up Health Plan Functions and Services

with the Practice

Placing the Tools and Services of the Health Plan in the Hands of the Provider

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Process Improvement

Sunday Monday Tuesday Wednesday Thursday Friday Saturday0

10

20

30

40

50

3436

33

25 24

35

49

Practice Site “R”: ED Visits by Day of the Week

Sept 2008 - Mar 2009 (n = 236)Data Source: EDW

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Process Improvement

1 am - 6 am 7 am - 11 am 12 noon - 3 pm 4 pm - 7 pm 8 pm - 12 mn0%

10%

20%

30%

8.9%

22.9%25.8%

23.3%

19.1%

Practice Site “R”: ED Visits by Time of DaySept 2008 - Mar 2009 (n = 236)

Data Source: EDW72% of ED Visits oc-

cur 7am - 7 pm

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Process Improvement

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Process Improvement

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Access E-visits

Acute Chronic

Remote Monitoring Interdisciplinary Team Meeting Supportive Services Transition Services Mobile Community-based Care Managers Pharmacy Consultation Behavioral Health Consultation Physician Rx for Lifestyle Health

Coaching

Hospita

l Admiss

ions

Readmiss

ions w

ithin

7 day

s

Readm

ission

s with

in 30

days

Readmiss

ions w

ithin

60 day

s

ED visit

s0

0.2

0.4

0.6

0.8

1

1.2

1.4

0.36

0.04000000000000010.14

0.25

1.07

0.190000000000001

0 0.05000000000000010.0800000000000002

1.33

Before Monitor Placement After Monitor Placement

*Readmissions within 60 days*

Adm

issi

ons/

Vis

its P

er M

onth

* Denote a statistically significant difference

Results: Admissions and ED Utilization Per Month Before and After Monitor Placement

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Conclusions: What Matters Culture Strategy Leadership Team Management Delivery Results

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