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The Milbank Memorial Fund is an endowed operating foundation that aims to improve population health by connecting leaders and decision makers with the best available evidence and experience. It does this work by:
The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
January 12, 2021
Multipayer Primary Care Network Primary Care Transformation Delivery System Reform
Diane Marriott Read Bio
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Since the advent of the patient-centered medical home and team-based care concepts, health reformers have sought to unearth the specific interventions and techniques in primary care settings that are most likely to improve patient outcomes and value.
For example, the Center for Medicare and Medicaid Services’ multipayer primary care demonstration projects, such as Comprehensive Primary Care Plus and Primary Care First, are using value-based payment and care delivery reforms to improve care quality and reduce unnecessary emergency department (ED) and inpatient utilization.
But what precisely makes a difference in primary care? To identify specific interventions or practice characteristics that are associated with high-performing practices, we leveraged the multipayer CPC+ Michigan dashboard made possible by the CPC+ participating payers (CMS, Blue Cross Blue Shield, and Priority Health) to find the practices in the top 20th percentile of performance on both ED and inpatient utilization and conducted in-depth interviews with each. We also collected and collated insights from leading health providers groups such as Ochsner, Geisinger, Stanford, ChenMed, and Village MD.
We identified the following six themes:
Physician engagement drives patient and practice team engagement and promotes a practice culture that embraces adapting innovations to improve care
Co-located, engaged teams with care management at the core are key. The size of team does not matter.
At SMG Okemos, the care manager’s office space is near the checkout window by design, to maximize interaction with patients. Some practices were very successful at using instant messaging for team-based care delivery, a practice that might be useful in times of required social distancing, such as during the COVID-19 pandemic. In addition, in high-performing practices, longitudinal and episodic care management was always conducted by the practice team (instead of centrally). All high performers used daily huddles, whether scheduled or impromptu. At Alimenti Family Practice, not only are there physician/team huddles at 5:30 pm each day to prepare for the next day’s patients, but also there are twice-a-week clinical huddles with the full clinical team, and monthly all-team meetings where success is celebrated and any crises are reviewed.
Offloading routine tasks (e.g., medication refills, gap closures) from the primary care physician workstream frees them to focus on patient needs and championing team-based care.
Availability and responsiveness to patient needs as well as patient awareness of the availability mattered more than extended hours.
Integrating performance reporting into regular team huddles or communication drives accountability for performance. Sharing provider-level performance regularly also motivated improvement among individual providers.
High-performing practices had a method for identifying patients who would benefit from interventions (e.g., care management, self-management programs; remote patient monitoring; etc.) All high performers studied readily recited their “triggers” for intervention and care management.
Hospital discharges were also a common trigger for extra patient support. At one impressive high-performing practice, Kozmic Family Practice, a “bridging clinic” coordinated post-discharge experiences for recently hospitalized patients. In the practices and systems studied, admission, discharge, and transfer outreach calls and gap closure calls were the only two functions that, though often performed within practices, were sometimes performed centrally without compromising outcomes. Both models worked as long as they were used systematically and connected the patient to the primary care practice quickly for follow-up.
Better understanding how high-performing practices achieve success offers an opportunity to share best practices and learnings. In Michigan we are using this work to develop our capacity to achieve team-based care and provide improved experiences and outcomes for patients. We believe that these lessons can be applied around the country.
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