Recent articles in national and Colorado media put patient-centered care, compensation to primary care physicians and HealthTeamWorks in the spotlight. The coverage highlights insurers’ adoption of new payment strategies for primary care — approaches that acknowledge the value of front-line care and its role in preventing high medical costs down the line.  

The Wall Street Journal described the intent of WellPoint Inc., a major national healthcare insurer, to pay primary care doctors 10 percent more — with the possibility of up to 50 percent from bonus payments. The article notes that primary care currently makes up a tiny 2.8 percent of the nation’s healthcare spending, yet holds enormous potential to curtail high costs through prevention, screenings and patient education. Wellpoint leaders hope that by investing in the patient-centered medical home (PCMH) model of care — which applies care coordination, improved access, patient self-management strategies, standardized care protocols and tracks patients’ outcome data — the company’s projected medical costs could drop by up to 20 percent by 2015, the article states.

John Bender, MD, and his practice, Miramont Family Medicine in Fort Collins, Colo., are featured as participants in the Patient-Centered Medical Home (PCMH) Pilot convened by HealthTeamWorks.

Although Meredith Rosenthal, PhD, the Harvard researcher evaluating the pilot, notes that the PCMH model has not yet demonstrated cost savings, “Wellpoint said its savings are based largely on its own data from medical-home pilot projects,” the article says.

Anthem to pay Colorado primary-care providers for patient-centered care

In Colorado, Anthem Wellpoint, the state’s largest private insurer, announced it will pay bonuses to its 2,500 contracted primary-care doctors because of the success of the HealthTeamWorks-convened PCMH pilot. An article in The Denver Post on Feb. 2 stated that “Anthem found that paying primary-care doctors more to coordinate patient care cut hospital admissions by 18 percent and emergency room use by 15 percent.”

According to Elizabeth Kraft, MD, Anthem’s chief medical officer, paying primary care providers more to deliver PCMH-model care “creates a return on investment of 2.5 times to more than four times.”

Those financial results from the pilot convinced Anthem to take its payment model for patient-centered primary care nationwide, the article states. Other leading healthcare carriers, such as Humana and UnitedHealthcare, are expected to follow suit.

Northern Colorado newspaper features local practices in PCMH Pilot

The Northern Colorado Business Report featured the PCMH Pilot, focusing on results from Miramont Family Medicine and Internal Medicine Clinic of Fort Collins. In return for a monthly per-patient fee, pilot practices offer patients round-the-clock access to providers and same-day appointments, and involve patients in treatment decisions. The practices take a population management approach to patients with chronic conditions such as diabetes, ensuring that all get regular blood-sugar checks, eye and foot exams and know the dangers of high blood pressure and smoking. By reaching certain measures for patient care, practices receive bonuses from the participating health plans.

By extending the value-based primary-care payment model to providers nationwide, healthcare payers are establishing the PCMH as the paradigm. This is an important step toward a transformed healthcare system that provides personal, efficient, measurably effective care.
 

The employees of HealthTeamWorks were proud to nominate our CEO, Marjie Harbrecht, MD, for the 9News Leader of the Year Award. Although she was not ultimately selected, Marjie was among the eight finalists.

Marjie responded to her staff by saying: “I cannot tell you how honored I was to even be considered for this and want to thank Eric Palmer, one of our quality improvement coaches, who introduced the idea, Allyson [Gottsman, HealthTeamWorks Executive Vice President] and the rest of the staff who ran with it, and Cissy Kraft, MD [HealthTeamWorks board chair]; Alfred Gilchrist [CEO of the Colorado Medical Society]; Scott Hammond, MD [Westminster Medical Clinic] and Tracy Hofeditz, MD [Belmar Family Medicine] who were kind enough to write letters of support. All of this meant more to me than the award itself.

“I truly believe the accomplishments achieved to date have been a TEAM effort – I could not do this without all of you,." Marjie continued. "You are at the forefront of changing healthcare and I’m proud to be working with all of you to help lead this effort!”

We regret that 9News did not select Marjie as the leader of the year, but regardless, she is our Leader of the Year.

The HealthTeamWorks staff

HealthTeamWorks, which extols wellness and self-care as part of its mission to improve the healthcare system, puts its muscles where its mouth is. The Lakewood, Colo.-based nonprofit’s approach to health and wellness for its own staff might serve as a model for other firms.

Each month, staff members compete to see who can log the most workouts, who can take the most steps, who can exemplify a heart-healthy lifestyle. “I organized the program to motivate myself,” says Sara Schwankl, who started the HealthTeamWorks wellness program a year ago, expanding on the idea of a colleague. “Most adults don’t get anywhere near enough exercise to meet national activity goals. By keeping each other supported and motivated, it’s easier to achieve activity targets. This program keeps us all accountable.”

Teams of four, with names like the FitWits and the Queens of Cardio, get credit for each member’s daily workouts of at least 30 min. Lifting weights, running, a brisk walk, skating, cycling, yoga — almost any activity counts if it increases the heart rate. 

Participation is voluntary, and nearly half of the 40-member staff has joined the initiative. Employees compete fiercely to end each month with the most workouts. Staff members — who range in age from 22 to 66 — exchange good-natured taunts and eye the tally board to see who’s leading. Members of the winning team get their choice of $10 gift cards.

A separate contest pits individuals against one another: Who can take the most steps in a month? Schwankl issued staff pedometers so everyone can record each day’s distance in a log.

Logically, HealthTeamWorks’ wellness efforts are in step with one of the clinical guidelines it develops for Colorado primary care physicians. The adult obesity guideline helps clinicians assess and treat overweight patients according to the best and most current medical evidence.

The company’s program also aligns with a number of national wellness initiatives, such as First Lady’s Michelle Obama’s Let’s Move program, designed to combat childhood obesity, and the Presidential Active Lifestyle Award, which promotes wellness for people of all ages. 

“This fitness program is great fun for the staff, and emphasizes our companywide belief in wellness and prevention,” says Marjie Harbrecht, MD, HealthTeamWorks’ CEO. “The coaching that we provide to medical practices includes a focus on healthy lifestyle, weight management and cardiac fitness. Thanks to pressure from my teammates, now I get to the gym more often!”

What does your organization do to encourage a healthy staff? We’d love to hear about it.

The epidemic of obesity in the United States has claimed one-third of adults — 33.8 percent. Obesity is defined as a body mass index (BMI) of 30 or higher. (Those with a BMI of 25-29.9 are considered overweight.) As the Centers for Disease Control and Prevention notes, “During the past 20 years, there has been a dramatic increase in obesity in the United States and rates remain high. In 2010, no state had a prevalence of obesity less than 20 percent. Thirty-six states had a prevalence of 25 percent or more; 12 of these states (Alabama, Arkansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Oklahoma, South Carolina, Tennessee, Texas and West Virginia) had a prevalence of 30 percent or more.”¹

The CDC’s Healthy People 2020 program aims for a 10 percent reduction in adult obesity over the next nine years.² The agency, along with the healthcare industry, wants to stem the surge of obesity-related conditions that include heart disease, stroke, type 2 diabetes and certain types of cancer. Not only do these conditions cause premature death, they also generate enormous medical costs. In 2008, obesity-associated healthcare costs were estimated at $147 billion; the medical costs paid by third-party payers for obese people were $1,429 higher than for those of normal weight.³

HealthTeamWorks has developed a clinical guideline on adult obesity to help providers address this often-difficult issue with patients. Easy to use and comprehensive, it covers clinical assessment, diet, physical activity, weight-loss medications, surgery, tips for families, goal-setting and approaches to counseling that engage the patient. An associated action plan for patients allows providers to work with them to set goals for reaching a healthy weight. Goals pertain to nutrition and physical activity; the provider can assist with the care-team support section, which has spaces for referrals, medications and community resources.

The guideline assists clinicians regardless of the cause of a patient’s obesity: genetics, inactivity, poor diet/eating habits, lifestyle, quitting smoking, pregnancy, lack of sleep, medication, age, socio-economic issues or medical problems.⁴

Because obesity represents such a major public health problem, and because losing even a modest amount of weight can prevent or improve morbidity, it’s imperative that clinicians address the issue with patients.

Sources
1. Centers for Disease Control and Prevention. Overweight Obesity — U.S. Obesity Trends. www.cdc.gov/obesity/data/trends.html, accessed Nov. 15, 2011.
2. Centers for Disease Control and Prevention. HealthyPeople.gov. Nutrition and Weight Status. http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=29#141, accessed Nov. 15, 2011.
3. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Aff September/October 2009 vol. 28 no. 5 w822-w831.
4. Mayo Clinic. Obesity. www.mayoclinic.com/health/obesity/DS00314, accessed No. 22, 2011.

Palliative care addresses pain and control of symptoms, seeking to improve quality of life during a treatable illness and during the dying process. Palliative care joins patients, healthcare professionals and families in a partnership to anticipate, prevent and treat suffering. More than pain control, palliative care should encompass physical, intellectual, emotional, social, and spiritual needs to promote a patient’s self-sufficiency.

HealthTeamWorks recently developed a clinical guideline on palliative care that is intended for, but not limited to primary care providers. This two-page, convenient reference is free for download or in hard copy form. As with all HealthTeamWorks guidelines, it is not meant to replace a clinician’s judgment or establish a standard of care.

Palliative care can begin in primary care setting

Palliative care can begin in the primary care setting, as early as diagnosis of a potentially life-limiting illness. It can be delivered along with curative or disease-modifying treatment. Because palliative care focuses on identifying treatment goals and managing pain and symptoms, primary care clinicians are ideally suited to initiate and coordinate it. Noting the importance of specialists, however, the guideline gives indicators for referral to specialty-level palliative care or hospice.

The guideline differentiates between palliative care and hospice care. It suggests questions that providers can use, adapt and revisit throughout the progress of illness to address the key elements of palliative care. These are:

• Advance care planning;
• Pain and symptom management;
• Emotional-social-spiritual needs and challenges;
• Caregiver burden; and
• Coping with decline and eventual death.

Expert panel developed guideline

HealthTeamWorks developed the palliative care guideline by convening a committee of physicians, advanced-practice nurses, and professionals in behavioral science, health communication and social work. Participants represented 11 Colorado organizations, including private practices, hospitals, hospices, the University of Colorado and healthcare insurers.

The committee identified existing evidence-based guidelines on palliative care and conducted a literature review on the topic. Its members built the guideline around key issues that providers need to know to deliver appropriate care, as well as what is not now being done that could make the most difference to improve care.

Following HealthTeamWorks’ usual procedure, a focus group of primary care physicians reviewed the guideline draft and made suggestions. HealthTeamWorks’ board of directors and membership reviewed the revised guideline, made further revisions and then gave final approval. The result is a carefully crafted, closely evaluated clinical tool in an easy-to-use format.

A beginning palliative-care tool set for clinicians accompanies the guideline.  

Prescription medications relieve all sorts of ills, but they are increasingly being abused for recreation or addiction. In 2002, the National Survey on Drug Use and Health reported that an estimated 29.6 million Americans had used pain relievers nonmedically; by 2005, the number had risen to 32.7 million.¹

In 2009, 45 percent of the nearly 4.6 million drug-related emergency room visits nationwide were attributed to abuse of pharmaceuticals.² The Drug Abuse Warning Network estimates that of the 2.1 million drug abuse visits, 27.1 percent involved nonmedical use of medications.³

Prescription drug abuse means taking a prescription medication that is not prescribed for you, or taking it for reasons or in dosages other than as prescribed. Abuse of prescription drugs can produce serious health effects, including addiction. Commonly abused classes of prescription medications include opioids, central nervous system depressants and stimulants.

HealthTeamWorks has just released a new clinical guideline supplement on prescription drug abuse prevention to assist primary care providers and others. The supplement is part of the SBIRT program — Screening, Brief Intervention and Referral to Treatment — that we offer to healthcare organizations free of charge. SBIRT Colorado partners with HealthTeamWorks to work directly with primary care throughout the state to integrate the Alcohol and Substance Use Screening Guideline into clinical practice.

The supplement includes screening questions, responsible opioid prescribing, behavioral health considerations, tips for patients and care-givers and resources for prescribers. Printed front and back on an 8 ½ x 11 inch page, the supplement, like all HealthTeamWorks guidelines, is concise and easy to use in the clinical setting.
All HealthTeamWorks’ clinical guidelines and supplements are available for free download.
 
To ask questions about our guidelines, e-mail egingerich@healthteamworks.org or call 720-297-1681.

Sources
1. Maxwell JC. Trends in the abuse of prescription drugs. The Center for Excellence in Drug Epidemiology, the Gulf Coast Addiction Technology Transfer Center, the University of Texas at Austin. http://www.utexas.edu/research/cswr/gcattc/documents/PrescriptionTrends_Web.pdf, accessed Sept. 20, 2011.
2. National Institute on Drug Abuse. NIDA InfoFacts: Drug-Related Hospital Emergency Room Visits. http://drugabuse.gov/infofacts/HospitalVisits.html, accessed Sept. 20, 2011.
3. Ibid.

One of the hallmarks of the patient-centered medical home (PCMH) is care coordination with members of its medical neighborhood — hospitals in particular. Because so many gaps in care can occur between primary and hospital care, the PCMH-Hospital Committee, convened by HealthTeamWorks, is working to identify and close those gaps and make patient “hand-offs” error-free.

By communicating with primary care physicians (PCPs), hospitals can improve care to patients in the emergency room by obtaining crucial health information. Medical practices can reduce patients’ emergency room and hospital visits — including re-admissions — through better care management, access and communication.

HealthTeamWorks established the PCMH-Hospital Committee in August 2009 with representatives of area hospitals, hospital systems, the Colorado Hospital Association, insurers and practices participating in the Colorado PCMH Pilot. It recently got renewed energy with the addition of Beth Neuhalfen, PCMH project manager for Westminster Medical Clinic (which participates in the HealthTeamWorks PCMH Pilot project), and Marsha Parker, MS, CPHQ, administrative director for quality and medical staff, St. Anthony Hospital North.

The committee aims to:

• Improve timely notification to PCMH practices when patients come to hospital emergency rooms or are admitted to the hospital so practices can act on the information; and
• Improve coordination and continuity of care through better communication between hospitals and PCMH practices, including determining the information that parties need to share.

“There are so many processes involved [between primary care and hospitals] that need changing,” Neuhalfen says. “It’s a journey of change. Our practice, as a PCMH pilot and model for other practices, can also be a model for working better with hospitals.”

“Hospitals have only looked at patients from when they enter our doors to when they leave,” Parker says. “Now, with a focus on partnership and coordination of care, we are starting to recognize a home-to-home perspective: What has the patient’s history been in other care settings, and how can the hospital assist in the patient’s care once they’ve gone home?”

The challenges facing the PCMH-Hospital Committee include:

• Resistance to change by hospital physicians, particularly those working under contract in the emergency room;
• Limited time for providers in primary care and the hospital to exchange information;
• Incompatibility between electronic health record systems;
• Patients’ inability to provide information about their PCPs; and
• Contracted physicians’ incentives to refer to care-givers outside a patient’s medical neighborhood.

“We’re identifying the information: who needs what, the best way to facilitate referrals to the emergency department, how hospital discharge advocates and primary-care coordinators can work together,” Neuhalfen says. “We have to include skilled nursing facilities and other kinds of services that reflect back to the PCP and reach out to the PCP.”

Neuhalfen and Parker both say that the committee is raising awareness of the importance of care transitions “We want to see what’s happening to people in the interim between providers.” Parker says. “A PCMH’s care coordinator can work with hospital care managers to make sure care never gets dropped. This eliminates a huge gap in care.”

“As someone who’s been involved in healthcare a long time, I know the incentives [for healthcare players] are misaligned,” she continues. “It’s very satisfying to see the focus coming back to the patient.”
 

Patients who take part in managing their chronic conditions, instead of leaving care entirely to medical providers, can enjoy a higher quality of life and a feeling of control over their health.^1,2 Conditions such as asthma, diabetes and hypertension (high blood pressure) respond dramatically to lifestyle changes, as well as to medications.
 
Self-management is a key component of the patient-centered medical home (PCMH). By engaging patients in their care, the PCMH team empowers them. This is extremely important for those living with chronic disease. Rather than feeling helpless and hopeless, patients with ongoing conditions who know how to care for themselves can feel activated, motivated and confident.

Self-management support is not the same as patient education, cautions Kathleen Reims, MD, a family medicine physician and quality expert. “Self-management support begins with the patient’s self-identified problems. A teacher — who can be either a healthcare professional or a peer — helps the patient with problem-solving skills that apply to any chronic condition.”

Patient education begins with the provider, Reims says. “The doctor, nurse or another health professional determines a patient’s need for education about a condition or illness. She or he gives the patient information and technical skills, such as how to perform an insulin injection. Patient education aims to make patients compliant with prescribed care; it’s often given in the belief that knowledge leads to behavior change, which is false,” Reims says. Research shows that information motivates people to alter behavior only 10 percent of the time.³

Self-efficacy is what leads to change. To support patients and their families in self-efficacy to improve health, the care team must facilitate self-management support. Reims recommends a few key steps to accomplish this: 

• Involve your whole team – Train physicians, nurses and medical assistants in self-management goal-setting, brief action planning
• Enlist clinical leaders – They must get practice wide recognition that self-management support is an essential part of care and lead by example
• Provide additional support to patients after the visit – Particularly for complicated, high-needs cases, use follow-up calls, texts, e-mails for coaching; focus on removing barriers, offer information
• Look beyond assumptions – Self-management failure may be due to literacy issues, undiagnosed mental health problem, cultural barriers, patient ambivalence or too-ambitious goals

“Because the PCMH does not operate in isolation, look for partners outside your walls to help patients in their self-management efforts,” Reims says. Community organizations, public health, schools, employers, and social and peer support networks can greatly augment the medical practice’s efforts. The more resources a patient has at his/her disposal, the greater the chances for ongoing self-management of chronic illness.

Sources

1. Lorig KR, Sobel DS, Stewart A, et al. Evidence Suggesting That a Chronic Disease Self-Management Program Can Improve Health Status While Reducing Hospitalization: A Randomized Trial. Jan 1999; Medical Care;37(1):5-14.
2. Norris SL, Engelgau MM, Narayan KM. Effectiveness of Self-Management Training in Type 2 Diabetes.
A systematic review of randomized controlled trials. Diabetes Care, March 2001;24(3):561-587.
3. Miller WR, Rollick S. Motivational Interviewing: Preparing People for Change. 2002, 2nd ed. New York; Guilford Press.

Read all about it! Our CEO, Marjie Harbrecht, MD, wrote the lead article in the June 2011 edition of Colorado Healthcare News. In “Patient-Centered Medical Home Pilot generating pivotal changes in healthcare delivery,” Harbrecht describes the purpose and progress of the Multi-Payer, Multi-State Patient-Centered Medical Home Pilot, which began in 2009 and runs through 2012. It is demonstrating that resources invested in primary care result in better care, reduced cost trends and an improved experience for the patient and the healthcare team.

http://www.colhcnews.com/index.html

Posted on behalf of Larry Green, MD

It is improbable that the structure and content of family medicine residency programs as designed in the late 1960’s would prove sufficient more than 40 years later to produce the family physicians needed across the country.  A period of experimentation has commenced, ignited by the Association of Family Medicine Residency Program Directors and the American Board of Family Medicine with a program called “Preparing the Personal Physician for Practice” (P4). 

P4 aspired to stimulate widespread innovations in family medicine residency training, and Colorado was quick to step up and out to organize the FM residency programs into an innovative learning collaborative, headed up by Perry Dickinson in partnership with HealthTeamworks.  This program is learning a ton about how important leadership, clear decision-making, quality improvement, and teamwork are in  Colorado’s residencies, and the focus on the PCMH has proven to be productive.   North Carolina has built from some of their prior work to organize something similar, placing them and Colorado at the leading edge of the very hard work of transforming training sites and curricula.  This journey is going to take awhile and it is hard work.  

A lot of organizations and national leaders know about what is going on in Colorado and point to it to make the case that even in the difficult, if not toxic, environment in which this redesign work is occurring, change and progress is possible and “spreadable.”  What is going on here is important, and it going to spread to other states.  Not unlike the beginning of FM in the 1960s when Ward Darley and Wes Eisle built from the University of Colorado General Practice Residency program to help design the current FM residencies, Colorado is doing more than its fair share to get the next redesign show on the road. 

Hats off to the residencies, Perry and his teammates, HealthTeamworks, and The Colorado Health Foundation!  This enterprise matters now and will matter more, favorably affecting a lot of residents and a lot of patients for years to come.