In its 2001 seminal report “Crossing the Quality Chasm:  A New Health System for the 21rst Century”, the Institute of Medicine (IOM) described the current state of health care delivery.  The report described a health care system that was fragmented, poorly designed and most importantly not delivering quality care. It also outlined a plan with very specific performance objectives designed to close the quality gap and support the patient-provider relationship. These objectives called for a radical redesign of the health system to achieve six aims—safe, effective, patient-centered, timely, efficient, and equitable care.  A new phase in health care improvement is now emerging: one that focuses on value. Value considers providing safe, effective, and efficient care at the right cost. The Institute for Healthcare Improvement (IHI) has developed a model for optimizing health, care experience, and costs for populations -- The Triple Aim. This is a structure in which we know and care about:

1. Patient and Family experience,
   
2. The quality of care delivered, and
   
3. How our efforts impact the cost of care.
   

I would add from my own perspective that we care about our community and providing care for all.

My career started working as a nurse in a hospital system before I moved to the ambulatory care setting. As a nurse there are moments in my career that haunt me. These tragic events had catastrophic impact on patients and families. It was not the failure of caring and competent staff which led to these haunting memories--it was the lack of systems and process to support evidence based care. These experiences drive my passion for a healthier health care delivery system.

In my current position with Colorado Beacon Consortium as Director, Community Collaboratives and Practice Transformation, I have the pleasure of helping primary care practices in transformation and learning from their amazing efforts. In my 15 years working with primary care practices, I have never met a staff member clinical or non-clinical who came to work hoping not to deliver the best possible care. Practices need support for these transformational changes.  Having a “small test of change” fail has meaning for clinical staff because of our educational experience. Failure in the clinical training means that a patient is harmed. Clinical staff need to understand that failures in the quality improvement process mean that the team will not be wasting their time on processes that do not bring value to their patients or to the practice.

In an era of incentive programs such as Meaningful Use and system designs such as Accountable Care Organizations, now more than ever strong Primary Care delivery systems is necessary for creating a healthier health care system. Primary Care transformation is integral is achieving the goals articulated in Crossing the Quality Chasm.

Now more than ever Primary Care needs support to transform systems and processes to make their best better. Redesign efforts started with the development of the Chronic Care Model by Dr. Edward Wagner and the MacColl Institute. The Chronic Care Model serves as a structure to organize care delivery for patients with chronic disease by maximizing proactive team based care, implementing processes which deliver evidence based care, utilizing health information technology (HIT) and delivering proactive care. Through several national organizations such as Health Resources and Services Administration (HRSA) Health Disparities Collaboratives, the Institute for Healthcare Improvement (IHI), the MacColl Institute and more recent initiatives such as National Demonstration Project and Improving Performance in Practice (IPIP) best practices in primary care transformation have been developed.

The Patient-Centered Medical Home (PCMH) has been recognized as a catalyst to support Primary Care transformation that delivers on the expectations described in Crossing the Quality Chasm. Agency for Healthcare Research and Quality (AHRQ) describes PCMH as:

• Patient-Centered
  
• Comprehensive  & Coordinated care
  
• Superb access to care
  
• A systems-based approach to quality and safety
  

These attributes must be supported by a foundation of Health Information Technology and rich data which provides knowledge to drive outcomes.  The other structural change must come in the form of a payment structure that supports primary care and the attributes that will drive the value primary care delivery will bring to healthcare.

A comprehensive program to recognize practices who implement the attributes of PCMH has been developed by the National Committee for Quality Assurance (NCQA) Physician Practice Connections- Patient-Centered Medical Home (PPC-PCMH). NCQA has recently updated the recognition program.

The 2011 program includes the core components of primary care:

• PCMH 1: Enhance Access and Continuity
  
• PCMH 2: Identify and Manage Patient Populations
  
• PCMH 3: Plan and Manage Care
  
• PCMH 4: Provide Self-Care and Community Support
  
• PCMH 5: Track and Coordinate Care
  
• PCMH 6: Measure and Improve Performance
  

The transformation process for primary care is more than tinkering around the edges. This process of change requires a foundation of culture and leadership that is supportive of the efforts within the practice. This can be either through the leadership structure of a broader organization or within a small independent primary care practice. The Primary Care Practice team members are being asked to reconsider the hierarchical nature of medicine for a team based approach to patient-centered care. All members of the team to participate in the redesign process and in evidence based care delivery. Practices establish structures to make “small tests of change” that are reviewed to understand if the impact is positive in delivering safe, effective, evidence based care.  Implementing self-management support with primary care builds on the most intimate of relationships between patient & families and the care team. Self-management techniques utilized in the care setting build on patient activation and engagement in their care. Technology is a tool to be maximized and utilized meaningfully.

Clearly, we understand the role of Primary Care in supporting our current sick health care system to become healthier. This transformation takes time and requires support. As we establish principles, goals, care models and incentive programs to create a healthy health care system, it is important not to lose sight of the need to also transform the current payment model with is perfectly designed to assure that our fragmented, ineffective, dysfunctional and harmful health care system continues.

Crossing the Quality Chasm

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Institute for Healthcare Improvement

http://www.ihi.org/IHI/Programs/StrategicInitiatives/IHITripleAim.htm

Improving Chronic Illness Care

http://www.improvingchroniccare.org/

HRSA Healthcare Communities

http://www.healthcarecommunities.org/

Agency for Healthcare Research and Quality

http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_

National Committee for Quality Assurance

http://www.ncqa.org/tabid/631/default.aspx

Office of the National Coordinator for HIT (ONC)

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__home/1204

Colorado Beacon Consortium

http://www.coloradobeaconconsortium.org/

Center for Medicare and Medicaid (CMS)

https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp

Partnership with Patients

http://www.healthcare.gov/center/programs/partnership/index.html

If you have concerns about health care legislation, you certainly not alone. Amid chants of “Kill the Bill”, several thousand Tea Party protesters stormed Capital Hill last month to voice their concerns about health care legislation and public polls indicate that most Americans are not pleased either. Ironically, many concerns are focused on bringing down quality of care, raising costs, and reducing the number of people able to purchase health insurance, directly opposing goals of the legislation. Is this just a case of lack of information about the bill? Kaiser Family Health News tackles some of these concerns and tells us, true or false.

"Access to health care is more than giving someone an insurance card. It requires that patients also be able to find a primary care physician who can provide first contact, comprehensive, continuous, preventive and coordinated care for most of their health care needs." -- Snippet from letter written by AAFP and several other primary Care organizations to Congress.

The American Academy of Family Practitioners and number of other primary care physician organizations sent a letter to Congressional leaders calling for more primary care provisions to be added to legislation. These groups have been saying for a long time that the pending primary care shortage is a major crisis that demands attention immediately, especially if coverage is extended through Medicaid to millions of the nation's poor. Low Medicaid payment rates make it nearly financially impossible for struggling primary care physicians to new Medicaid patients and will only exacerbate the shortage.

Check out the AAFP press release to get an idea of what additions Primary Care Organizations are calling for.

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As America continues to struggle to pull out of our current economic recession, the need to reform our national health care system becomes more and more essential to the sustained fiscal health of our national and local economies.  In 2007, the United States spent approximately $2.2 Trillion dollars on health care, which translates to roughly a 16% share of our gross domestic product (GDP). Health care spending is not just a long-term federal budget issue; rising health care premiums, costs of services, and high deductibles are rapidly and covertly bankrupting the middle class. In 2007, at least 62% of all personal bankruptcies in America were linked to illness and medical debt, although roughly three quarters of these individuals had health insurance, were college educated, and owned homes.

To say that cost control and savings policies should be essential aspects of health legislation is a gross understatement. Given the financial stakehold that health care has in our economy, significant cost control and savings policies MUST be apart of health legislation. However, a Washington Post article indicated yesterday that many experts fear that the House and Senate health care bills are too timid on cutting costs and broader changes are needed.

Here are a couple of the concerns highlighted in the article:

-- A Senate plan to tax high-priced insurance policies saves far less money -- and is less likely to change medical consumption -- than eliminating the tax exemption for employer-sponsored coverage.

-- Proposals on comparative-effectiveness research and a new Medicare cost-cutting commission have been watered down.

-- An array of Medicare pilot projects aimed at paying doctors and hospitals for quality rather than quantity would take years to be implemented nationally -- if they ever were.

-- None of the bills addresses medical liability, even though the Congressional Budget Office has concluded that tort reform could save $54 billion over the next decade.

In May, Obama and Health Care Industry leaders promoted policies that were estimated to save $2 trillion dollars in health care spending, but only a few of these policies, such as streamlining insurance claims forms have been included in legislation.

Many critics of pending health care legislation sing the same tune: they fundamentally endorse the ideas included but warn reforms fall short of the cost savings possible and that pilot projects may take too long to adopt broadly and may not achieve the cost savings needed.

Hope Street Group feels strongly that for health care reform legislation to be successful, it is imperative that legislation reforms the system to be both fiscally responsible and sustainable, with changes to the health care delivery system designed to reduce system wide future health care cost growth, including federal and state government programs.

Interested in reading the full Washington Post Article? You can find it here.