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The Medical Home:The Medical Home:Building a Blueprint
May 2, 2011
P i h I d B h i l H l h S iPresentation to the Integrated Behavioral Health SummitDebbie Peikes, Ph.D. Jan Genevro, Ph.D.
David Meyers, M.D. Charlotte Mullican, M.P.H.
The Medical Home: Working to Achieve the Triple Aims
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Goals of This Talk
1. To update mental health integration experts p g pon AHRQ’s work on the patient-centered medical home (PCMH) – In collaboration with Mathematica, LA Net, NCQA
2. To entice you to learn more about our work yto support improved outcomes via enhanced primary care– http://www.pcmh.ahrq.gov
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The Pieces
I. Foundational Work
II. Evidence Review and Synthesis
III. Implementation
IV Di i tiIV. Dissemination
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I. Foundational Work: Definition of the Medical Home
A medical home is not simply a place, but a p y p ,model of primary care that delivers care that is: – Patient-centered– Comprehensive, team-based– Coordinated
Accessible– Accessible– Continuously improved through a systems-based
approach to quality and safety
AHRQ believes that Health IT, workforce development, and payment reform are criticaldevelopment, and payment reform are critical to achieving the potential of the medical home
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Database of Articles
Database of published literature on the pmedical home– Over 850 citations– Searchable by PCMH domain, population (including
people with behavioral and mental health issues), policy relevance, and outcomesp y
– Includes a section on foundational documents and articles
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White Papers and Briefs
Foundational White Papers (and Decision p (Maker Briefs*)– Integrating Mental Health into the Medical Home– Necessary but Not Sufficient: The HITECH Act’s
Potential to Build Medical Homes*– Engaging Patients and Families in the Medical Home*Engaging Patients and Families in the Medical Home– The Roles of PCMHs and ACOs in Coordinating
Patient Care– Coordinating Care in the Medical Neighborhood:
Critical Components and Available Mechanisms
Stay Tuned for More!
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Spotlight #1: Integration
Integrating Mental Health Treatment into the Patient-g gCentered Medical Home – Tom Croghan, Jonathan Brown, June 2010
Normalize mental health care into mainstream medical practice—truly adopt a whole person approach to care
Integrate reimbursement for the time and resources needed to provide mental health treatment in the PCMHneeded to provide mental health treatment in the PCMH
Develop performance measures to encourage adoption f i t ti hil idi f iof integration while providing a source for ongoing
feedback and improvement opportunities
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Spotlight #2: Practice-Level Research Design
Choosing the Sample and Sample Size for g p pMedical Home Evaluations: How to Ensure That Studies Can Answer Key Research Q tiQuestions– Deborah Peikes, Stacy Dale, and Eric Lundquist,
forthcomingforthcoming
Stay tuned at: http://www.pcmh.ahrq.gov
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Designing and Analyzing Practice-Level Studies
Avoid false positives by analyzing data correctly
Avoid false negatives by designing adequately powered studies
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Why Do Practice-Level Evaluations Need to Account for Clustering?
Failing to account for clustering in the analysis will lead to false positives because effects will (mistakenly) appear to be statistically significant
70%
75%
False Positive Rates When Ignoring the Effects of Clustering
50%
55%
60%
65%
(α)
Risk when clustering is ignored
30%
35%
40%
45%
e Po
sitiv
e R
ate
10%
15%
20%
25%
30%
Fals
e Risk when clustering is accounted for
0%
5%
10%
0.00 0.01 0.02 0.03 0.04 0.05 0.06 0.07 0.08 0.09
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Intra-Cluster Correlation Coefficient (ICC)
Designing Adequately Powered Studies: Take Home #1
Invest in including more practices rather than gmore patients– PCMH evaluations should include 35 or more
practices to detect effects for chronically ill patientspractices to detect effects for chronically ill patients• It is better to include more practices • The right number varies depending on the patients,
outcomes, and practice patterns– Evaluate results for ~100 patients per practice
• Not much payoff statistically for more patients/practiceNot much payoff statistically for more patients/practice
Caveat: Medical home interventions still can be designed to serve all patients in a practicedesigned to serve all patients in a practice – We can limit our samples in the evaluation
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Take Home #2
Meaningful practice-level evaluations must g paccount for clustering– Not doing this will increase the chance that we
l d th i t ti i ff ti h it iconclude the intervention is effective when it is not
– Invest in a statistician
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Take Home #3
Different outcomes should be evaluated differently
For cost and hospital and ED utilization: For cost and hospital and ED utilization:– Measure intervention only for patients with significant
chronic illnesses• Actionable• Less variation in outcomes so easier to detect effects
– Can also try to reduce the influence of outliersy
Even an evaluation of 50 practices would need to generate reductions of ~25-30% to detect an effect among all patients
The same intervention would need only a ~10-15% effect to be detected among patients with chronic illness
For quality-of-care and patient experience outcomes:– Measure outcomes for all patients (but may limit to a sample
from each practice)from each practice)
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Summary
When implementing an intervention, it is better p g ,to include more practices than more patients to yield the highest quality evaluation
Evaluations must account for clustering, or they risk falsely suggesting the intervention is effective when it is not
Medical homes should care for all patients butMedical homes should care for all patients, but evaluators should look at high-risk patients when measuring costs and utilization– We have not investigated patterns among patients with
mental health needs
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II. Evidence Review and Synthesis
Robust synthesis of the current state of PCMH yevaluations and 18+ individual summaries of interventions that have been evaluated– The Medical Home: What Do We Know, What Do We
Need to Know?: A Review of the Current State of the Evidence on the Effects of the PCMH Model
Deborah Peikes, Aparajita Zutshi, Kimberly Smith, and Melissa Azur
Look for them at: http://www.pcmh.ahrq.gov
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Federal Collaboration
AHRQ heard from federal partners and external stakeholders about the need to coordinate f d l ti iti d th PCMH dfederal activities around the PCMH and primary careI AHRQ d F d l In response, AHRQ convened a Federal Collaborative on the PCMH
Share information so that participants have a– Share information so that participants have a common understanding of PCMH
– Foster collaborations and share expertise– 172 members representing 14 agencies, including
SAMHSA
AHRQ ill bli h id i AHRQ will publish a guide to primary care activity across the federal government (including DHHS VA and DOD)(including DHHS, VA, and DOD)
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III. Implementation
Developing a manual on practice facilitation p g pfor primary care transformation
Convening an expert working group of national Convening an expert working group of national leaders to develop the manual for new and existing programsg p g– Experts in the use of practice facilitators/coaches in
primary care
Will cover both PCMH transformation and more general primary care practice g p y pimprovements (e.g., integrated care)
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IV. Dissemination Website and Other Avenues
PCMH AHRQ Govhtt // h hPCMH.AHRQ.Govhttp://www.ahrq.pcmh.gov
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Acknowledgments
With thanks to other members of our team: Mathematica: Erin Taylor, Myles Maxfield, Gene
Rich, Rachel Machta, Jenna Libersky, AparajitaZutshi, Kathleen Kohl, Kristin Geonnotti, Stacy Dale Eric Lundquist Marsha Gold Claire GillDale, Eric Lundquist, Marsha Gold, Claire Gill, Jung Kim, Jessica Nysenbaum, Lorenzo Moreno, Amy Krilla, Debra Lipson, Tom Croghan, Jonathan Brown, Tim Lake, Kim Smith, Melissa Azur, Greg Peterson, Jennifer Baskwell, Stacy Pancratz
S b t t L N t L d K NCQA Subcontractors: LaNet: Lyndee Knox; NCQA: Sarah Scholle, Phyllis Torda; Geisinger Health System: Tom Graffy
AHRQ: Michael Parchman, Rachel Weinstein
Many many outside experts
Mathematica® is a registered trademark of Mathematica Policy Research.
Many, many outside experts
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For More Information
Please contact:– Debbie Peikes
– Jan Genevro• [email protected]
– David Meyers• [email protected]
– Charlotte Mullican• [email protected]
Mathematica® is a registered trademark of Mathematica Policy Research.
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