Link Round Up

Today we are featuring some links focusing on primary care:

  • Medical Care published a special supplement, featuring articles discussing the Safety Net Medical Home Initiative: “a multistate, multiyear initiative to bring the medical home model of primary care to the most vulnerable U.S. populations, including low-income and underserved communities.”
  • Our research collaborators at Oregon Health & Science University and Kaiser Permanente Center for Health Research published an Op Ed in The BMJ. They discuss the Oregon Experiment and how increasing access to primary care will improve health.
  • A recap of Oregon Health and Science University’s Center for Health System Effectiveness conference on Health Care Reform
Waiting Room

A Warm Welcome to the Next Wave of APM Health Centers

The next wave of health centers has come on board to the Alternative Payment Methodology (APM) pilot. The APM pilot is a health care payment system where Medicaid pays participating community health centers a set amount per patient per month for each enrollee, whether or not the person seeks care. For the past year, our research team has been studying the first wave of APM clinics; we are trying to understand whether this shift in payment is changing the way clinics provide care. Now a whole new group of centers will be tackling these important changes.

The first phase of the pilot program started in March 2013 with three Oregon Community Health Centers: Virginia Garcia Memorial Health Center, Mosaic Medical, and OHSU Family Medicine at Richmond. These first three APM care systems actually worked with the state and other organizations to develop the model. Now, in Phase II of the APM pilot, five more health centers are starting to implement APM: Coastal Family Health Center in Astoria, Community Health Centers (CHCs) of Benton and Linn Counties, Multnomah County Health Department in Portland, OHSU Scappoose in Scappoose, and Yakima Valley Farm Workers in Yakima Washington.

The second-phase APM adopters represent a range of regions and health center sizes. For example the Coastal Family Health Center in Astoria is a small, semi-rural clinic, but their managed care organization was interested in becoming part of the pilot. Multnomah County, on the other hand, is a big health center treating an urban population. Yakima Valley Farm Workers Clinic, which has several Oregon sites in addition to Washington, is the first clinic to start the APM with a different Electronic Health Record (EHR) system. All of the health centers voluntarily chose to participate in the pilot.

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Coordinated care team

A Nurse a Day Keeps the Doctor Away

Rethinking health care teams

 The clinics at the forefront of implementing the Alternative Payment Methodology (APM) are very excited to think more about new ways of providing care to their patient populations. Under APM, clinics receive a capitated per-member per-month rate, thus shifting the financial incentive from office visits with a physician towards providing team-based care. According to the Oregon Primary Care Association (OPCA), the APM model “removes old bottle necks,” and enables community health centers (CHCs) to transition from “the provider centric model of care delivery to a more advanced, team-based model.” The hope is this payment model will enable patient-centered primary care homes (PCPCH) to address a wider range of health factors.

These organizations on the frontlines of rethinking primary care have an opportunity to revisit some basic questions: What’s the ideal patient panel size?  Who manages the patient panel? And more generally, what does the care team look like?

Physicians as medical care specialists

The role of the physician is evolving during the transition to PCPCH. While it may seem counter-intuitive, medical staff point out that the medical component of a typical clinic visit is only a small piece of the time they spend at the clinic, and many patients do not need to see a medical person at all. It is in this light that the medical care provided by the physician can become a highly trained specialty within the overall health care team.

Laurie Francis, a Senior Director of Clinic Operations and Quality with the Oregon Primary Care Association (OPCA), explains that many patient needs can be addressed by other members of the care team and don’t require the expertise of a physician.  “When I’ve talked to family practitioners and the internal medicine doctors who are doing this work, they estimate that maybe about fifteen to twenty percent of their day is actually needed for a medical visit.  This means for eighty percent of the day, most of the patients don’t need to see a medical person. They need social support, economic support, psychological; all the things that we know cause people to be chronically ill for a long period of time.” Continue reading

A Medical Student’s Perspective

By Glenn Kautz, MPH

For the average medical student in their first two years, the words “health systems innovation,” provokes a similar reaction as “quantum mechanics;” a vague concession that the concept exists, followed by a momentary consideration of why that might be important, a shrug, and finally a resumption of trying to memorize 1023 facts before dawn.

While our most basic motivation stems from helping our future patients, the daily Sisyphean pursuit of medical knowledge shapes us into experts at deciphering what we must learn in order to survive academically. Thus, the focus is most often on the what, and not the why.

That is, until we interact with patients in weekly clinical rounds, or through volunteer work. It is then that the why becomes perfectly lucid. We find ourselves saying, “aha,” as the lectures, notes and mnemonics suddenly manifest in perfect order as the basis for a metabolic disorder, or the clearing of an infection. We become reinvigorated with wonder and motivation for understanding all we can.

As a research intern studying health systems innovation, the same process applies. My head swirls as I grapple with impossible complexities; hospitals, state and federal policies, study designs and alternative payment models (APM). But when I visit a Federally Qualified Health Center (FQHC) utilizing an APM to best serve their patients, the minutia comes to life, the dots connect and I realize why learning the details is so important.

Medical students are invariably curious people who learn how to approach knowledge acquisition in the most efficient possible way. The shear magnitude and complexity inherent in health system innovation can be daunting and often acts as a barrier to medical students’ pursuit of knowledge in this critical area of health care. But these same barriers exist for biochemistry and physiology. What keeps us going is a faith that this knowledge will help us to help others.

When they see the why for learning about this vital component of their future profession, I believe the task becomes imperative, and much less daunting. I hope that many of my fellow students will share my good fortune and see innovation, because only by engaging can we hope to make a positive impact on our patients and communities.

Glenn Kautz, MPH, is a second-year medical student at Oregon Health and Science University (OHSU), working with OCHIN and OHSU Family Medicine as a summer research intern through a grant from the Oregon Academy of Family Physicians.  He is interested in a primary care, underserved populations and health policy analytics. 

APM: Empowering New Ways Of Providing Care

Part 2

By Erika Cottrell, Jill Arkind and Sonja Likumahuwa 

In Part 1 of this post, we discussed how the shift of the payment model allows community health centers the opportunity to leverage the care team to provide better care. We conclude by offering more examples of  team collaboration made possible by the new payment model. 

(Note: This article originally appeared in Health Affairs Blog on July 21, 2014. An edited version is being reposted here as part of the research effort investigating the impact of Alternative Payment Methodology (APM) on the delivery of primary care in safety-net populations. Through this website, Frontiers of Health Care, we are sharing lessons learned and perspectives from key stakeholders on the frontlines of reform.)

Team Meetings And Huddles

In addition to the changes discussed in part one, another is the weekly care team meetings. Before APM, VG staff tried to do team meetings, but “we didn’t feel like we could pull people off the floor” and some providers resisted dedicating an hour a week to meetings in lieu of seeing more patients. Now, VG provides sample agendas to help to structure the content of the weekly team meetings and a centralized area for posting notes and sharing best practices and lessons learned. Sample agenda items include discussion of ways to improve workflow, how to proactively address patient panel needs, and group exercises on how to efficiently utilize the various skills of the team members.

Team functioning has been quite varied, and much of it depends on the physician who is leading the team. “Some teams have done well and some teams have needed a lot more guidance. The task of structuring and leading care team meetings has largely fallen on the physicians, who aren’t really trained to be group facilitators or team leaders,” says Hill. Despite the variations, team meetings have given care teams more dedicated time for panel management, and at VG, they give care teams a lot of leeway to try new things.

They also started having “huddles,” where either part of the care team or just a provider and medical assistant meet in the morning to discuss the patients that they will see that day. Guerreiro admits to having mixed feelings about the weekly full team meetings. However, he has found smaller group “huddles” to share panel information and plan the day to be extremely useful. Continue reading