Humboldt Del-Norte Primary Care Renewal “ A Regional Collaboration to Improve Population Health,...
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Humboldt Del-Norte Primary Care Renewal Primary Care Renewal “ “ A Regional Collaboration to Improve A Regional Collaboration to Improve Population Health, Individual Patient Population Health, Individual Patient Experience, and Lower the Total Cost of Experience, and Lower the Total Cost of Care” Care” Alan Glaseroff MD, CMO Humboldt Independent Practice Association Humboldt ITUP Conference 12/1/09
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Transcript of Humboldt Del-Norte Primary Care Renewal “ A Regional Collaboration to Improve Population Health,...
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ePrimary Care RenewalPrimary Care Renewal
““A Regional Collaboration to A Regional Collaboration to Improve Population Health, Improve Population Health,
Individual Patient Experience, and Individual Patient Experience, and Lower the Total Cost of Care”Lower the Total Cost of Care”
Alan Glaseroff MD, CMOHumboldt Independent Practice
AssociationHumboldt ITUP Conference
12/1/09
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eDeterminants of Health and Their Determinants of Health and Their Contribution to Premature DeathContribution to Premature Death
Schroeder, NEJM 357; 12
15%
5%
10%
40%
30% Social
Environmental
Medical
Behavioral
Genetic
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ePatient Driven CarePatient Driven Care
• Patients are the most important factor in their own outcomes
• Patients receive care from someone they know and trust
• Patients are able to access information directly
• What is the role of the care team in this “Reformation”?
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eThe Care Model – The Care Model –
“The Wheel Invented…”“The Wheel Invented…”
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eCore of Chronic CareCore of Chronic Care
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e““A Little Assembly Required…”A Little Assembly Required…”
• “The person who invented the wheel was pretty smart, but the person who invented the other three was a genius!”
Uwe Rheinhart, Princeton Health Economist
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Patients
Hospital Services Family
ClinicianPractice
Friends and Family
Specialists
Community
The Medical Home: The Medical Home: It Depends on Your Point-of-View…It Depends on Your Point-of-View…
The “empowered patient” view…?
Neighborhood Gym/
Recreation
Place of Worship
Workplace
Internet
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eHumboldtHumboldt
• IPA– Started in 1996– 350 member IPA (210 physicians, 80 mid-levels, 60 mental health professionals)
– 7,500 HMO members, 4,000 PPO and self-funded
– > 95% of all providers including safety net, average practice size 3 MDs
– 84 PCPs– BOD 50/50 PCPs and specialists– Unaffiliated with hospitals– Humboldt Diabetes Project: 83% of all pts with DM in registry; NCQA Recognition for DM 2004
– “Top Quality” in CA P4P program
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ePractice Environment in Practice Environment in
HumboldtHumboldt
• 25 primary care practices in various sizes, types and stages of transformation (all in the Humboldt IPA)– 2/3 of patients receive care in either FQHCs or
Rural Health Clinics– 5 community health centers, Mobile Medical
Clinic, United Indian Health– Many rural health clinics (small practices)– Many 1-3 clinician practices in private
practices (one 17 MD Internal Medicine practice)
– No large integrated multispecialty group– Managed care covering 5% of population
• How to rapidly improve chronic disease care in the community?
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ePrimary Care Renewal in Primary Care Renewal in
HumboldtHumboldt
• Trip to Group Health/Factoria and Care Oregon August 2008 to look at Medical Home/Care Support projects: “Build Your Own…” so we did
• Dr. Ed Wagner launch 11/08• 14 teams 1/08• Added peer-educator team (POET) 10/09• Model for Improvement meets “5 Aims”
– Clinician “permission”– Starts with team mtgs (process measure for collaborative)
– MAs as medical professionals
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• Team mtgs• Model for Improvement:• Pro-active Panel Management
– Preventive and chronic care measures, “closing the loop”
• Access– ED visit comparative report and patient stories
• Patient-Driven/Integrating Behavioral Health– POET-led session – problem-solving from patient perspective
++
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eWhat We Have Learned So FarWhat We Have Learned So Far• Exhortation/fear of exposure/incentives not enough: “Enlightened self-interest – imagine the perfect clinical day(dream)…”
• “Always start from the patient’s view”• Clinicians need
– Best practices– Coaching– Comparative data/feedback
• Workforce Development– MA II curriculum/certification– RN Care Support/Population Management– Peer-educators/coaches/navigators
