In this lesson, we'll look at areas of improvement that involve patient management. This includes, the Institute of Medicine's framework for improving healthcare quality and the Triple Aim, which is an example of how medicine or healthcare is evolving in the US today. We'll look at emerging concepts of accountable care, value based purchasing and coordinated care. After this lesson, you'll be able to describe current evidence based efforts to transform fragmented care processes into coordinated patient centered activities. The Institute of Medicine in 2001 published a report titled, Crossing the Quality Chasm, and it outlined six aims to improve healthcare quality in the US. These six elements provide a goal based framework for improving the quality of healthcare and they include, healthcare that is safe, effective, patient centered, timely, efficient, and equitable. The reason these six elements are so important, is that they constitute the different measurements by which we are accounting for the quality of healthcare in the US today. Frequently we measure the quality of healthcare using these elements which originated from the IoM report of 2001. One of the reason that healthcare in the US is changing, is that reimbursement model of healthcare is clearly not affordable anymore and is not creating a higher quality of care. We need to change the reimbursement and align incentives so that providers are rewarded for providing a higher quality of care rather than simply providing more care which might lead to a lower quality. For example, many procedures have risk associated with them, so more care might increase the complication rate based on what is done to the patient because of the medical care process. A 2006 Institute of Medicine report titled, Rewarding Provider Performance Aligning Incentives in Medicare, noted that the existing fee-for-service payment system, rewards excessive use of services, high cost complex procedures and lower quality of care. My hope is that this type of information will help you see some of the changes that are happening in health care, which in turn might also require the use of health care analytics. Medicine is evolving, the old model was primarily a counter based and involves professional autonomy and little standardization of what types of care and treatments patients receive. Do no harm was an individual responsibility and secrecy was necessary. The new paradigm in health care is that care that is based on a continuous healing relationship. It is tailored to the patient's needs and values, safety is a core property of the system. Thus it's not up to the individual anymore, health care delivery systems are created to provide more scientific and evidence based care in which transparency is a requirement. Dr. Wagner of Group Health in Seattle said it well. Overcoming deficiencies and correct disease management will require nothing less than a transformation of healthcare from a system that is essentially reactive, responding when a person is sick to one that is proactive and focused on keeping a person as healthy as possible. In sum, the transformation of healthcare in the US is happening right now, or at least that is the emphasis of a lot of the reforms that are happening. Let's now review The Triple Aim which is really a framework developed by the Institute of Healthcare Improvement describing an approach to optimize healthcare system performance. It really is three concurrent strategic aims. First, better care for individuals, second, better care for populations and third lower growth and expenditures. Frequently, healthcare organizations can engage change and cause one or two or three of these to change. But having all three of these chains together is quite difficult. But all three must change to improve healthcare in America and to improve on the Institute of Medicine's six elements of measurement. What important concepts are associated with The Triple Aim? First, it is accountable care, the second is patient centered medical home, the third is coordinated care, and the one final one is value based purchasing. Let's start with Accountable Care. Accountable Care organizations are partnerships between physicians and hospitals to coordinate healthcare services to improve efficiency and increase quality. There are really three parts here that are the key principles of accountable care. First, is accountability where you foster organizational accountability for outcomes quality and cost across patient practices and perhaps multiple hospitals. Second, there's performance measurement. This is comprehensive and transparent measurement of outcomes quality and costs. The third, is payment reform where the payment is provided for better value as measured by improved patient outcomes, better quality and reduce costs. It is not about cost reduction by itself, it's about increasing quality relative to cost and thus providing a higher value. The Affordable Care Act or ACA a it's known, encouraged the formation of Medicare ACOs through demonstration projects. So, the ACA had a certain amount of funding to encourage demonstration projects that experimented with this new concept known as accountable care. The ACA gave the Department of Health and Human Services at the federal level, the authority to establish new regulations for Public Sector ACO's and outlined eight goals. First, put beneficiaries of families at the center of all activities. Which is very different than the traditional medicine which has really been centered around providers and hospitals. Two, coordinate care for all beneficiaries at anytime and location. Three, play strong importance on care transitions. This includes data exchange to support safe and effective transitions of care. Four, manage resources to reduce waste and increase value for beneficiaries. Five, create communication programs that focus on helping patients with health maintenance. So, not focusing on certain crisis, admissions or events, but to put in place a health program or health improvement program. Six, collects and evaluate and use data to measure efficacy. Seven, be innovative in the service of the three part aim or the Triple Aim. And then eight, ensure continuous development of the workforce and physicians, particularly working on the culture of medical practice that supports these goals. Next, let's talk about the Patient-Centered Medical Home or the PCMH. The concept has a long history. It was first introduced in 1967 by the American Academy of Pediatrics. The goal at the time was to aggregate all paper records for each child into one home practice. So, that's what the meaning of the medical home means, it refers to the patient being part of a single practice which manages all aspects of their care. The concept has evolved to include the transformation of practice towards coordinated care through adoption of EHRs and other health information technology, tracking performance measures to improve patients access to care through open access scheduling, and to be proactive in terms of managing their conditions between office visits. In some respects, that is perhaps more important than just managing things at office visits and not having any contact with the patient in between. So, really the Patient-Centered Medical Home is all about patient engagement. In some respects it is really at the early part of the continuum if you look at the patient medical home as really it's a chronic disease management program. How does the PCMH work? It's a team based healthcare delivery model. You have a combination of providers ranging from physicians to nurse practitioners who provide comprehensive and continuous medical care to a cohort of patients. Just because the patient is not on the office does not mean that attention is not paid to them. It is managing a population of patients and being proactive. The characteristics are that everyone has a personal physician who directs the medical practice and is responsible for ongoing care. The orientation is patient centric, thus coordinated care is really essential tenet in this practice. And who's in the medical home? Well, these patients for whom that provider is responsible for providing the comprehensive care. This would exclude the one visit patients. For example, patients who are being seen in urgent care and who are transitioning geographically, or maybe you were on a trip and you stop in an emergency department but you're really getting care elsewhere. Various definitions have been suggested for PCMH populations. In one example, some medical centers include patients who have had a telephone or an in person encounter. If they've had two or more in the past 24 months, they're considered being within the cohort that would be considered the population for this patient centered medical home. Okay. In this module there are a lot of details about organizations that are working to create standards for patient centered medical care, specifically with models such as Patient-Centered Medical Homes. Overall, managing the finance of healthcare is important for increasing access to health care for uninsured Americans, yet high cost and variable levels of quality must be addressed before any sustainable solution will be reached. In my opinion, there is a need to transform the culture of medicine that is currently based on physician autonomy to a system in which medical providers work as a team to provide patient centered care. The internet may be one force that will empower patients to learn more about their health and then motivate them to work together with their providers to achieve the best possible outcomes. Once patients have more information about their health, and are better able to understand risk and benefits of their options, it is likely that they will select less costly treatments that will lead to higher quality outcomes. It is likely that once physicians embrace these changes, they will enjoy working with patients who have the capacity to understand more about complex health issues. Thank you for being here and I will see you in the next module.
