Health care providers are under tremendous pressure to achieve the Triple Aim of better health for designated populations, better care experiences for patients and reduced cost of care. It comes at a time of enormous transition in health care, in which successful models are hard to find and refine. That's what's so encouraging about the model of personalized primary care that we have been developing at Intermountain Healthcare. The lessons we've already learned are informing our expanding rollout of the model and enhancing the potential for broader scaling.
The transitions that health care providers face are extraordinary and simultaneous:
- Businesses are no longer accepting cost-shifting.
- Government and private insurers increasingly are paying for value and outcomes, not volume; they are also employing new payment models for hospitals and clinicians.
- Health care reform is creating increased demand, and doctors and hospitals are consolidating, among other approaches.
Crucial to achieving the Triple Aim in this shifting context is shared accountability, or more fully engaging all of the participants in health care in the pursuit of higher-quality care, which frequently leads to the additional benefit of lower costs. Everyone — hospitals, physicians, nurses and other caregivers, employees, insurers, plan members, patients and their family members — has a role to play.
Personalized primary care, also referred to as a patient-centered medical home, involves three core components: team-based care, mental health integration, and clinician and institutional leadership at all levels. These components exist within a context of shared accountability as well as shared decision-making, which involves ongoing communication between clinicians and patients about a disease or therapy when faced with the task of making unique and complex medical decisions.
Team-based care requires new participants and an entirely different approach to collaboration. Key participants on a clinic-based care management team include:
- the primary care clinician;
- a registered nurse care manager;
- a medical assistant health advocate, who organizes team huddles, prepares for patient visits, supports the care manager, and provides patient engagement and education;
- advanced practice registered nurses and physician assistants, who support patients during care transitions, improve access and extend the clinical leadership of the internist, family practitioner and pediatrician.
Primary team members share accountability for patient outcomes, maintain an ongoing relationship with the patients that is focused on achieving their individual goals, and work with partners to ensure seamlessness in transitions.
Team-based care is designed specifically to achieve the goals of the 2011 standards for the patient-centered medical home set by the National Committee for Quality Assurance. Those standards include: enhancing access and continuity, identifying and managing patient populations, planning and managing care, providing self-care and community support, tracking and coordinating care, and measuring and improving performance.
Mental Health Integration
Integrating mental health requires a new level of collaboration between mental health specialists and primary care physicians. Mental health care is delivered at the primary care office by psychologists, licensed clinical social workers, psychiatric advanced practice RNs and psychiatrists. A registered nurse care manager supports the medical and social needs of patients and coordinates team huddles, often over brown bag lunches, to ensure that shared learning improves the knowledge within the team.
The integration of mental health services within the personalized primary care model is crucial for several reasons: severely and persistently mentally ill clients die approximately 25 years earlier than the rest of the population; preventable medical conditions are the leading cause of premature death among these clients; behavioral health clients have higher rates of co-occurring conditions including hypertension, diabetes, obesity and asthma; and behavioral health clients are less likely to receive care that meets clinical guidelines.
In our testing of mental health integration, we have found that clinics with such integration, when compared with clinics that lack it, have less medical expense with mental health diagnoses, less medical expense overall, lower utilization of the emergency department for all reasons, increased patient satisfaction, and increased clinician and team satisfaction.
Leadership at All Levels
Clinician and institutional leadership in support of personalized primary care comes from local physician, nursing and operational leaders; involvement of Intermountain Medical Group and SelectHealth (Intermountain's health plan) senior leadership teams; and direct engagement by the board of trustees and Intermountain Healthcare senior leaders. The board sets specific goals, and senior leaders are directly tied to achieving them.
This combination of local and high-level engagement is essential for the transformation of a large-scale health care system. In Intermountain's case, we have 22 hospitals, a medical group with 185 physician clinics, an affiliated health insurance company — SelectHealth — and 34,000 employees serving patients and plan members in Utah and southeastern Idaho.
What we've found in designing and implementing this personalized primary care model is that the results are meaningful and deliver on the Triple Aim; that data analysis is important, as clinic-based teams receive feedback on their efforts to improve health care delivery; and that clinic-based teams must come together and dedicate themselves to improving key clinical processes. There is significant additional expense with the introduction of care managers and health advocates, and it takes two to three years to effectively and fully implement.
That last point is part of the reason that institutional leadership is so important. There's an up-front cost that will be recouped later through the Triple Aim, and the results are not immediate.
The key lessons that we've learned include the following:
- Sustained quality improvement depends on the interpersonal relationships of team members, including relationships between professions.
- Implementing this model is a sustained effort with obstacles that must be overcome.
- To maximize return on investment, we must focus on the patients who are at the highest risk and whose conditions are most complex.
- The clinic-based care management teams need to know those with whom they deal at the health insurance providers.
Although at Intermountain we have the advantage of an affiliated health insurance company, we still are organizing regular get-togethers for our care managers with their counterparts at health insurance companies with whom we regularly work. This will create relationships that will support patients by moving what might otherwise be anonymous electronic and telephonic handoffs to a communication between colleagues on behalf of shared patients. It extends the concept of team-based care. We also are sharing best practices and learning from physicians and their teams who are working on implementing patient-centered medical homes.
Sustained quality improvement is never easy. It's even more difficult in complex organizations during complicated times with shifting pressures. Yet, sustained quality improvement is achievable, and personalized primary care is a proven vehicle for that challenge.
Mark Briesacher, M.D., is the senior administrative medical director of the Intermountain Medical Group at Intermountain Healthcare, a nonprofit health care provider based in Salt Lake City.