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National Center for Primary CareMorehouse School of Medicine

Integration: The N B W dNew Buzz Word

George Rust, MD, MPH, FAAFP, FACPMFather of Dan & Christina, Husband of Cindy,

Professor of Family MedicineDirector, National Center for Primary Care

National Center for Primary Care at Morehouse School of Medicine

Promoting Excellence in Community‐Oriented Primary Health Care and Optimal Health Outcomes for all Americans

WHO

WHO World Health Report 2008 Reaffirms Primary Care 30 years after Alma Ata Declaration of Health for All.

• Primary Care Matters!!!

Best Practice Model:JCAHO‐Accredited, 

Patient‐Centered, Open‐Access, Culturally‐Relevant, 

Community‐Governed, Quality‐Driven, Quality riven,

Behaviorally‐Enhanced, System‐Integrated, 

Primary Care Health Home

• West Orange Farmworker Health Association’s Family Health Centers circa 1989 ‐‐ Apopka, FL

Patient‐Centered Medical Home

Checklists or Transformation?

• Change is hard enough; transformation to a PCMH requires epic whole‐practice re‐imagination and re‐design.

‐‐ Paul Nutting

Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009 May-Jun;7(3):254-60.

Integration“We need a comprehensive, integrated approach to serviceintegrated approach to service delivery. We need to fight fragmentation.” 

‐‐WHO Director‐General, 2007

Five Levels of IntegrationPopulation Outcomes

Community

Healthcare SSystem

Practice

Person

2

Integration! Population Outcomes

Community

Healthcare System

Person‐LevelIntegrating 

h i l l hPractice

Person

Behavioral Health & Primary Care

• Behavior Change

• Mental Health

• Substance Use

Mental Health  Physical Health

“Baseball is 90% mental ‐‐ the other half is physical." 

‐‐ Yogi Berra

Cherokee Health Systems “Integrated Care” Model:

Prevalence of Depression in Chronic Disease

Prevalence of Depression in Chronic Disease

51%

42%

23%27%

Why Primary Care?Why Primary Care?

23%17% 16%

12% 11%

Parki

nson's

Cance

r

Diabet

es CVA

CAD MI

HIV

Alzhe

imer's

Clinical Scenarios

• Diabetic patient with depression

• Insomnia patient with nervios

• Schizophrenia patient gains 100 lbs, and develops diabetes

• Bipolar patient on lithium has hypothyroidism and high blood pressure

• CHF patient who self-treats PTSD with alcohol

• Chronic back pain patient develops opioid addiction

Choices Real People Make

Diabetic Patient with Depression

Agree to Accept Referral and then Don’t Go

Accept Referral to Psychiatry Practice

Deal with Mental Health Problem in Primary Care Setting Only

Get Help XAvoid Stigma XGet Optimal Treatment X XCoordinate Medical & Psych Rx

X ?

Behaviorally-Enhanced Primary Care

Gregory E. Simon, MD, MPH; Wayne J. Katon, MD; Elizabeth H. B. Lin, MD, MPH; Carolyn Rutter, PhD; Willard G. Manning, PhD; Michael Von Korff, ScD; Paul Ciechanowski, MD; Evette J. Ludman, PhD; Bessie A. Young, MD, MPH Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus. Arch Gen Psychiatry. 2007;64(1):65-72.

Continuum of Integration

Separate Referral Coordinated Collaborative Integrated

Separate Co-Located Common

Coordinated Care

• Tracking & Confirmation of Referrals & Follow‐up

• Sharing of Medical Records

Sh i f P ibi• Sharing of Prescribing Changes & Medication Lists

• Inter‐Operable Electronic Health Records

• Mutual Participation in Effective Health Information Exchange 

Collaborative Care• All of the Above plus . . . 

– Team‐Based Case Conferences– Frequent Interaction on Therapeutic Strategy– Patient‐Centered, Shared Decision‐Making– Shared Care Management– Joint Decision‐Making on Medication Changes

– Frequent, secure communication by phone, e‐mail, & videoconferencing

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The Power of IntegrationWhat would happen if all the health professionals

Faith Communities

Mental H lth came

together and created a therapeutic community of healers for whole people?

Health

Substance Abuse

Treatment Primary Care

Integration! Population Outcomes

Community

Healthcare SystemPractice‐Level

Practice

Person

Panel‐based, Team‐Driven Care & Outcomes Management 

Primary Caring‐‐ Healing with our “Radical Human Presence” 

• Listening• Touching• Affirming• Comforting• Diagnosing• Treating• Grieving• Supporting• Healing

Radical Human Presence is a phrase used in a presentation called “How the Heart Learns” by Landon Saunders; AAMFT, 2004 annual mtg.

20th Century Primary Care NCQA / HEDIS Quality Measures for Comprehensive Diabetes Care

Quality Indicator

Performance (Medicaid)

Performance (Medicare)

Performance (Commercial)

A. Good HbA1c Control (< 7) 30.9% 45.9% 41.8%B. Partial BP Control (<140/90) 57.3% 57.8% 61.4%B. Good BP Control (<130/80) 30.4% 30.2% 29.9%C. Cholesterol Control (LDL <100)

30.6% 46.9% 43.0%

Primary Care is Relational Care

Personalismoy  Confianza

Teamwork! • Community Health Workers (Promotoras)

• Medical Assistants• Nurses / Nurse Practitioners• Pharmacists• Social Workers • Health Educators• Oral Health Professionals• Physical Therapists• Primary Care Practitioners• Psychologists • Behaviorists• Sub‐Specialty Physicians• Administrators

Nurse Care Managers• Impact of a diabetes resource nurse (DRN) case manager in a suburban 12‐physician 

7.2%6.6%

8.9%

6.8%

5.0%6.0%7.0%8.0%9.0%

B fp y

family practice on quality care and outcomes 

Proc (Bayl Univ Med Cent). 2003 Jul;16(3):336-40. Clinical outcomes in patients with type 2 diabetes managed by a diabetes resource nurse in a primary care practice. Couch C, Sheffield P, Gerthoffer T, Ries A, Hollander P. Family Medical Center, HealthTexas Provider Network, Baylor Health Care System, Garland, Texas, USA. ce.couch@BaylorHealth.edu

0.0%1.0%2.0%3.0%4.0%

Geriatric Non-Geriatric

BeforeAfter

Teamwork:  LPN’s & Medical Assistants   (every team member working up to the level of his/her license)

77%

72%74%76%78%

BeforeAfter

• Example: Empower More Clinical Staff to Initiate Preventive

68%66%

67%

60%62%64%66%68%70%72%

Intervention Control

• McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians.Gen Intern Med 1997 Jun;12(6):357‐63

to Initiate Preventive Services

• Medical assistants and Licensed Practical Nurses offer mammography as a routine part of the clinic encounter

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Five Preventive Services Could Save  over 100,00 Lives*

• Aspirin advice 45,000 lives

• Smoking advice  42,000 lives

• Colorectal CA screening• Colorectal CA screening14,000 lives

• Flu shots 12,000 lives

• Breast CA screening  3,700 lives

116,700 lives

* If we increased from current levels of performance to 90%.

Teamwork! Enhanced Asthma Education via Community Pharmacists

– Symptom scores    50%

– PEFR values  11%

– Beta‐Agonist Use  50%

– Days off school / work 0.6 days/month

– ED Visits 75%

– Medical Office Visits 75%

– Quality of Life Scores 19%

McLean W, Gillis J, Waller R. The BC Community Pharmacy Asthma Study: A study of clinical, economic and holistic outcomes influenced by an asthma care protocol provided by specially trained community pharmacists in British Columbia. Can Respir J. 2003 May-Jun;10(4):195-202.

Staffing Models:(8,000 patientpanel) 

• 5 MD’s’

• 2.5 MD’s

• 3 PA’s

• 1 NP/Care Mgr

• 1 LCSW or Psychol/Behav• 2 PA’s

• 1 RPH

Psychol/Behav

• 1 DDS + hygienist

• 1 Pharm D (+ pharm tech)

• 3 Promotoras

Hamster Care  Health Outcomes 

Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood). 2011 Mar;30(3):439-45.

Patient‐Centeredness = Patient‐Defined QualityContinuous, Rapid‐Cycle Change 

(Faster PDSA Cycles)

• Alliance for Clinical Education – Guidebook for Clerkship Directors, 3rd Edition.  Available at http://familymed.uthscsa.edu/ACE/chapter3.htm

In a fast‐changing world, we don’t have time for ready‐aim‐fire any more; it’s fire‐aim, fire‐aim, fire‐aim . . .Tom Peters, Passion for Excellence

Patient Flow

Front‐Desk Check‐In

Medical Records

Waiting Room

Appointment Phone Calls

Nursing – Vital Signs

Clinician Visit

Pharmacy Lab Tests

Cashier / Check‐Out

Workflow Re‐Design

Front‐Desk Check‐In

Medical Records

Waiting Room

Appointment Phone Calls

Nursing – Vital Signs

Clinician Visit

Pharmacy Lab Tests

Cashier / Check‐Out

Integration! Population Outcomes

Community

Health Systems

Healthcare Systems Level: 

Practice

Person

•Information Systems

•Delivery Systems  (Pharmacy, Specialty Care, Emergency Dept,  Hospital, etc.)

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Health Information Systems

• Practice Level:  Individual Level:  • Average A1c level 

in all diabetics

• % of Patients with A1c > 8

• Lists of patients with A1c > 8 for outreach / action

• Flags or triggers to promote compliance at each visit and to decrease missed opportunities

• Evidence‐based guideline alerts

Re‐Set the Default:  Make Excellence Automatic

• Measure A1c on 

DCA 2000: $8 / test

•CLIA waived

•Reagent-filled cartridges

•6 minutes to test result

•Also does micro-albumin and Creatinine

every diabetic visit 

A1c Now: $13 / test

•CLIA waived

•No maintenance - disposable

•8 minutes to test result

•Fingerstick or venipuncture

•FDA cleared for home use Bayer DCA2000

Systems Change:  Re‐Designing Processes of Care

Step 1

• Diabetic gets finger‐stick blood glucose;  patient may have fasted

Step 2

• Doctor sees patient, and may order Hemoglobin A1c test. 

Step 3

• Patient may go to the lab and may wait to get their HbA1c drawn.

Step 4

• Doctor may notice that HbA1c is elevated 

Step 5

• Dr. may ask staff to call patient back for follow‐up 

Step 6

• Doctor / nurse may be able to reach patient by phone.

Step 7

• Patient may agree to come back, and may actually keep appt.

Step 8

• If patient comes back, doctor may intensify regimen.

Systems Change:  Re‐Designing Processes of Care

Step 1• Nurses follow standing order for fingerstick Hgb A1C on every diabetic

•Results on chart when doctor sees patientStep 2

•Results on chart when doctor sees patient;  

Step 3• Doctor may intensify regimen 

•Avg A1c 8.55 before•Avg A1c 7.84 after

Tele‐Health Home Monitoring

Managing Transitions, Managing Between the Lines

Process for knowing right away when your patient has been to the ER

Able to exchange patient info with the 

hospital duringa patient’s 

hospitalization

Create A Real System of Caring at the Community‐Level

Mental Health

HospitalsFaith

Communities

Emergency Room

Primary CareBusiness & Community

Leaders

Public Health

Integration! Population Outcomes

Community

Healthcare System

Community‐Level:P ti t t h

Practice

Person

• Patient at home

• Family and culture

• Social Determinants 

Doctor‐Centered Medical Home: the Exam Room and the Doctor‐Patient Visit

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Free‐Range Humans 

(when patients escape from the exam room!)

Individuals

Family

Neighborhood

Community

Environment

Cultural Relevance / Cultural Ownership

South Central Foundation – Anchorage, Alaska

High Tech  High TouchAppropriate Technology

• Framingham Risk Calculator for PDA

Community Health Workers (Promotores de Salud)

Triangulate Interventions

Children

Primary Care & Public Health

Family &Community

SchoolsPsychologists & Behavioral Health

Community as Real Partners on the Team

Healthy Patients, Healthy Communities Healthy Patients Need Healthy Communities

The Continuum of Community Health 

Example:  Why Do We Need Teamwork to Improve Outcomes in Obesity & Diabetes?

Example: To prevent complications of obesity and diabetes, all you have to do is modify a person’s health beliefs and attitudes, daily habits, eating preferences, daily activities, exercise habits, grocery stores, neighborhood walk-ability, food advertising, self-care, employability, economic empowerment, access to medical care, provider quality, and medication adherence, all in the context of his or her family and social relationships.

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Integration! Population Outcomes

Community

Healthcare System

Population Level Outcomes

Practice

Person

• Clinical

• Economic

$ Charges Due to Uninsured Hospital Admissions (All‐Cause & ACS Conditions)

Hospital Admission Hospital admission for ACS Conditionage group Count Rate/100,000 Total Discharge 

$$ Charges $$Count rate/100,000 Total Discharge 

$$ Charges $$

<1yr infancy 3381 2166.8 13052692 30 19.2 2400851‐4 early childhood 533 89.6 4982660 278 46.7 1882363

5‐12 later childhood 515 44.7 5938480 221 19.2 191493513‐19 adolescence 2179 225.5 38505983 417 43.2 5008118

20‐29 early adulthood 11959 847.1 295608834 2546 180.3 37563398

$

30‐44 young adulthood 21240 1005.7 509586602 4801 227.3 8041016145‐59 middle adulthood 26799 1375.4 779924179 6409 328.9 124391039

60‐74 later adulthood 6130 583.6 212189003 1379 131.3 2883029975+ older adulthood 438 100.4 15137085 74 17.0 1829954

Sum $1,874,925,518 $282,070,352

Table 3. Uninsured patient hospital admission/ hospital admission for ACS condition count and rate per 100,000 population and total hospital discharge by age group among Georgia residents in 2009

Indigent Care Hospital Costs (assuming 35.6% cost to charge ratio) – all‐causes of hospital admission

Indigent Care Hospital Costs (assuming 35.6% cost to charge ratio) –hospital admissions due to ambulatory care sensitive conditions

$667,473,484 $100,417,045

Primary Care Community Health Centers Impact on Uninsured ED Visits 

31% Excess

62% Excess

No CHC = 37% Excess ED Visits

Closing the Loop, Accelerating Cycle Times 

• Practice‐Level Data• Monthly ED Visit Rate• Hospital Bed‐Days• Preventable Adverse Events

• Person‐Level Feedback• Missed refills• Inadequate Care• ED Visit yesterday!

Focus on Global Health Outcomes for Complex Mental Health & Medical Co‐morbidities 

One Diabetic Patient:• Diabetes• Arthritis

COPD

• Pneumonia • Cancer

D i

ip op md ot m2 dg total

$217,657 $7,105 $29,756 $10,498 $3,155 $12,182 $280,353

• COPD• CHF•Stroke

• Depression•Alcohol / substance abuse

* 21 ER Visits * 143 hospital bed-days

Drivers of Health Disparities

Health Potential

WorstPotential

Minority

Average

Majority

Best / Optimal

Disparities = Human Tragedy

•Almost every day in Georgia a baby dies who would not have died if 

there was no black‐white difference in infant death rates (331 excess infant deaths 

in 2006)

Unequal Benefit –Breast Cancer

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Excess Cost Due to Racial Variation in Hospital Admissions by Disease

(mid‐range estimate)

ExcessHospital Admissions(mid‐range)

Hospital Charges Attributable to Excess Hospital Admissions (mid‐range) 

Payer Costs Attributable to Excess Hospital Admissions (mid‐range) 

A th 2 044 $28 687 330 $13 339 608 45

$

Asthma 2,044 $28,687,330 $13,339,608.45 

Diabetes 3,955 $92,172,057 $42,860,006.51 

Heart Disease 5,021 $187,289,234 $87,089,493.81 >Coronary 

Artery Disease 1,287 $65,156,724 $30,297,876.66 

>Congestive HeartFailure 5,868 $162,561,372 $75,591,037.98 

HIV 1,644 $76,784,134 $35,704,622.31 

Tying it All Together to Achieve Optimal, Equitable Health Outomes

Community Health

Primary Care

Medical Promotion

Health Outcomes

Medical Home

Accountable Health Care Entities

Transformation

• It may be hard for an egg to turn into a bird: it would be a jolly sight harder for it to learnit would be a jolly sight harder for it to learn to fly while remaining an egg. We are like eggs at present. And you cannot go on indefinitely being just an ordinary, decent egg. We must be hatched or go bad. 

‐‐ C.S. Lewis

29 babies saved!!!

Disparities Success Stories!

Decline represents 29 infant deaths prevented    (expected vs. actual)

Five Levels of IntegrationPopulation Outcomes

Community

Healthcare SSystem

Practice

Person

Integration means working 

seamlessly together!

Humility in Working Together

“We are all as angels,with only one wing;

We can only fly when we embrace each other.

-- Luciano de Crescenzo