Walmart changed the pharmaceutical retail industry forever by creating the $4 Prescription Program. In one fell swoop, a gargantuan company disrupted part of the health care ecosystem. Today it looks like they are taking a new angle on how to manage in store health clinics. In the past, Walmart utilized a separate company that ran health clinics within the store but these closed in 2008 after about 3 years in operation. By partnering with St. Dominic in Mississippi, Walmart has made a deliberate choice to support local health care professionals ability to provide care to their community.

This type of movement directly ties with Hope Street Group’s belief that using new places to deliver primary care can achieve greater capacity at lower cost.

You can read more about this here: Walmart to open clinics in stores , The Clinic at Walmart and Recommendation 3: Use new people, places, and tools to achieve greater capacity at lower cost.

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

Where does the healthcare continuum really begin?

With prevention?

In the home?

With the Primary Care Provider?

In the Emergency Department?

Although an argument can certainly be made for any of the four choices above, I’d like to challenge your opinion and perspective with a different answer…the continuum for many begins with Emergency Medical Services (EMS).

This past year I had the privilege to be included in two standard setting and forward thinking discussion forums-- AHRQ’s 2010 Annual Conference and HCIE Innovators Event as well as Hope Street Group’s Policy 2.0: Using Open Innovation to Reinvent Primary Care Project. Both of these events offered diverse perspectives from diverse participants in academia, corporations and all levels of government and localities who gathered to discuss and make recommendations to improve the health care system. Interestingly, the first responder perspective of EMS was only a footnote in these discussions. I believe that policy makers and leaders within healthcare all too often fail to look outside their sphere of influence and familiarity for answers or more importantly the critical questions. That said, I know this minimalization was not intended or planned, but a result of historical processes and comfort levels.

The numbers…

EMS contributes 15% or 17.25 million patients to the nations 123.8 million annual Emergency Department (ED) visits (CDC, 2008), yet Fire, EMS or Law Enforcement respond to over 240 million 911 calls per year (NENA, 2009). It’s difficult to accurately breakdown the national percentages of 911 call types, but upwards of 60% of EMS calls are generally considered low-acuity or non-emergent. To put this into a local perspective, the City of Tucson AZ with a population of approximately 530,000 (2005) generates approx. 79,000 Fire and EMS 911 calls per year, 84% or ~67,000 of these are medical in nature and 60% of those, ~46,000 require only Basic Life Support (BLS) care (TFD, 2009).

So what does that really mean? It means that the 911 system provides a substantial safety net for the Nation’s healthcare system. While this should come as no surprise, the volume of patients utilizing EMS, Emergency Departments and the 911 system continues to grow. Over 15 years ago, the National Highway Traffic Safety Administration and the Health Resources and Services Administration joined with leaders from the EMS community to put forth an EMS plan that would require significant collaboration with acute care, primary care and public health. This provided one of the earliest, nationwide, use of the scale-up-and spread model and was published as the1996 EMS Agenda for the Future (NHTSA, 1996).

The past…

To implement that vision and professional template, EMS has continued to grow it’s service provision model from one that was historically created for stabilization and transport of the acutely ill and injured; one that was set-up to intervene only when patients needed emergent support; one that operated in relative isolation from other health care and community resources; one that was not involved in the business of ensuring social service follow-up and one that did not have a working knowledge of community health care providers and regional health care organizations (NHTSA, 1996).

The present…

Today, EMS is integrated with other health care providers, public health and public safety agencies to provide community-based healthcare and management. EMS agencies and providers are involved in activities related to prevention education, illness and injury risk, acute illness and injury care, follow-up, treatment of chronic conditions and community health monitoring. This vision is also shared by the Injury Response Division of the National Center for Injury Prevention and Control/Centers for Disease Control and Prevention (NCIPC/CDC) and the American College of Emergency Physicians (ACEP) who have called for a better understanding of roles and collaboration between Public Health and EMS through their Appleseed Project initiative (CDC, 2004).

The reality …

As you can see, EMS has developed into more than a group of fire departments, rescue services and ambulance companies. While providing these additional and collaborative services, EMS remains the public’s emergency medical safety net.  Looking back to those 240 million 911 calls and the 17.25 million EMS-to-ED admissions, it’s clear that a significant amount of health assessment, care and triage occurs outside the hospital walls. In fact, there are no other healthcare providers that see patients in their own home or living environment quite like EMS. The “scene assessment” which is a fundamental EMS skill reveals more information about a person, their living conditions, their health, their support system and their coping mechanisms than any other assessment tool.  How many Primary Care providers, case managers or health plan administrators have this perspective into their own patient’s lives?

From where I sit with over 30 years of experience as an RN in Maternal-Child Health and EMS, I see several important questions that need further discussion and clarification before we can begin to understand how to move forward in improving the healthcare of our Nation.

• How can we better educate individuals to utilize the 911 system for acuity appropriate reasons?
  
• How do we encourage the use of Primary Care practitioners for non-emergent and urgent medical and injury complaints instead of defaulting to the approach of “if this is a medical emergency, please hang up and dial 911?
  
• How do we share the burden of after-hours and weekend low-acuity patient needs?
  
• How do we facilitate better communication and collaboration between EMS, public health, acute and chronic care case management, behavioral health and community services?
  
• How do we move patients calling 911 for non-emergent or non-healthcare reasons into a public or human services system that will better meet their needs?
  

Communication, collaboration, connectivity, consistency and caring are all functions of healthcare, yet as the patient numbers and range of patient complaints increase, we all need to utilize each others skills, knowledge and expertise to meet the needs of our patient population. Reaching out to our colleagues may be the first step toward improvement, integration and understanding of our healthcare system.

http://www.911dispatch.com/info/fact_figures.html

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/nhamcsed2008.pdf

http://cms3.tucsonaz.gov/sites/default/files/imported/data/demographic/eecpop00_05.pdf

http://www.nena.org/911-statistics

http://www.cdc.gov/injury/publications/index.html

http://www.nremt.org/nremt/about/emsAgendaFuture.asp

http://www.tucsonaz.gov/fire/AnnualReport.pdf

We can all agree that we have reached a point where the status quo in prevention is not enough.  Obesity continues to negatively impact adults’ lives and the lives of future generations.  Heart disease continues to affect thousands of Americans and is the leading cause of death for men and women.  Disparities in health outcomes by class and race persist, despite advances in technology and even improved access.  Whatever we have been doing is simply not enough.  Now is the time for truly innovative thinking in prevention.

Despite looming shortages, the United States is fortunate to have an expansive network of physicians, nurses, and other practitioners.  Unfortunately, health does not happen in hour-long office visits, let alone in 15-minute office visits.  Health happens at home.  It happens on the job, in schools, on the playground, and in our neighborhoods.  We cannot expect primary care to have an improved impact if we do not improve our efforts.  The Patient Protection and Affordable Care Act is a great start, but providing better health care coverage, albeit important, is only a minute piece of the complex puzzle we know as “health.”  Individual health is shaped and impacted by a wide variety of factors, including many that we think of as outside the realm of typical primary health care practice.  Racism, discrimination, housing quality, neighborhood safety, income, transportation, education and the availability of fresh food – just to name a few – all play a role in our health.  These social and economic factors are collectively known as the social determinants of health and impact all people.  Disparities arise because some people have more and better resources for coping with the factors that have a negative influence, while others have very few or no resources.  (To learn more about the social determinants of health, please visit the links provided below.) 

Work has already begun to address many of these factors from both policy and grassroots perspectives.  Organizations such as PolicyLink and Prevention Institute have been highly active in getting some of these issues on local, state, and federal policy agendas.  The First Lady’s Let’s Move! initiative is a great example of a large-scale, comprehensive effort to bring awareness to the factors that contribute to obesity in children.  Let’s Move! not only encourages healthy eating and physical activity, but seeks to improve access to healthy food and empower parents and caregivers to make good nutrition choices for their children.  The Let’s Move! website reports that since the initiative launched in February 2010, more physicians and pediatricians have conducted Body Mass Index screenings.    Those results are interesting in their own right, but it begs the question what else can primary care providers do to help their patients live the healthiest lives possible.

Some might argue that everyone has a unique role to play in this fight for better health outcomes, that primary care providers do not have control over these external forces, and that it is not right to expect them to engage in something they didn’t sign up for.  I agree that it is not reasonable to expect primary care to be able to change the situations their patients encounter outside of the care settign, but I do believe that health care providers have a duty to do as much as possible in the best interest of their patients.  Health Leads (formerly Project HEALTH) is an organization that has successfully implemented an innovative model for increasing primary care’s role in addressing the challenges many people face on their journey to health and wellbeing.  In the Health Leads model, volunteers fill “prescriptions” that care providers write for resources such as food, housing, job training, and fuel assistance.  Patients are connected with resources in their communities to help them protect and improve the health of themselves and their families.  Health Leads and many others are working towards a world where disease is not just managed but prevented and where well-being is promoted.

Primary care, with its connection to communities and to individuals, is in prime position to take on an expanded role in the fight for health and we must continue to ask ourselves tough questions. What is primary care’s evolving role in creating and implementing sustainable solutions that help all people achieve and maintain optimal health? How can we better help patients navigate the terrain encountered outside of clinic and office visits?  What does disease prevention mean in a social and economic context?  I don’t have all of the answers as to how this can happen or what exactly should be done, but I know that it can and that it should.   

Resources

WHO: Commission on Social Determinants of Health

http://www.who.int/social_determinants/thecommission/en/

Unnatural Causes

http://www.unnaturalcauses.org/

CDC: Health Disparities and Inequalities Report, 2011

http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

Marmot Review: Fair Society, Healthy Lives

http://www.marmotreview.org/

RWJF: A New Way to talk about The Social Determinants of Health

http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428&cid=xtw_rwjf

PolicyLink

http://www.policylink.org/site/c.lkIXLbMNJrE/b.5136633/k.F267/PolicyLink_Center_for_Health_and_Place.htm

Prevention Institute

http://www.preventioninstitute.org/about-us.html

Health Leads

http://www.healthleadsusa.org/

Determinants of health: the role of the general practitioner?

http://www.primary-care.ch/pdf_d/2009/2009-15/2009-15-249.PDF

Recently, two of our key advisors have been featured in the media due to their success in providing direct health care services using both innovative and underutilized methods.

A recent New Yorker article by Atul Gawande highlights one of our advisors and panelists for the primary care event, Rushika Fernandopulle, MD. His practice in Atlantic City, New Jersey recruits and trains frontline health workers to serve the functions of both health coaches and medical assistants for 1,200 patients with multiple chronic illnesses.

The New York Times just featured advisor Tom Lee, MD as one of the pioneers of affordable concierge practices in the country. Lee, also a co-founder of Epocrates, has been able to extend visit times, engage in email communication and additional services provided by personalized “concierge” medical practices, but at a much lower price: $150 to $200 a year.

Access the full articles:

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande

http://www.nytimes.com/2011/02/01/health/01medical.html

Nova Scotia Premier Darrell Dexter has announced in a speech earlier this month plans for a $16-million collaborative primary care clinic in Queens County. The overarching goal is to bring Better Care Sooner to Nova Scotia residents by reshaping how emergency care is delivered.

The collaborative care clinic will have space for five  family  physicians, a nurse practitioner, family practice nurses and  other  health professionals.The new plans also call for an upgraded 22-bed  inpatient unit.

Additionally the Better Care Sooner is poised to:

-improve access to primary care, especially in smaller communities.

-make emergency care more patient-centered and streamlined.

-provide care that is better tailored to those whose needs are more complex (i.e. seniors).

-increase public awareness of 911 and the healthlink nurse line 811.

-make changes to the way health care is funded (reward better, patient-centered care).

The government states that roughly 84 percent of ER visits at the hospital would be better addressed by primary care.

Dexter says the province is committing $2.5 million to the project while the Region of Queens Municipality has committed $1 million.

About $11 million comes from the Queens Foundation and private donors, and another $1.5 million still needs to be raised.

Check out the whole story at http://www.canadaviews.ca/2010/12/23/improvements-will-ease-er-overcrowding-access-to-care/

Biography

Peter Urbanowicz is a Managing Director with Alvarez & Marsal Healthcare Industry Group in Washington, D.C. Mr. Urbanowicz brings more than 20 years of experience in solving challenging healthcare matters in government and private industry. He advises management, boards of directors, investors and lenders on healthcare compliance and regulatory issues, performance improvement, corporate governance and government and internal investigations.

Most recently serving as Executive Vice President, General Counsel and Secretary of Tenet Healthcare Corporation (NYSE: THC), Mr. Urbanowicz was responsible for successfully resolving all federal and state investigations and criminal and civil lawsuits facing Tenet by the United States Department of Justice, the Securities and Exchange Commission, the Office of Inspector General of the Department of Health and Human Services and several state attorneys general and United States Attorneys' Offices.

Prior to this, Mr. Urbanowicz served as Deputy General Counsel of the United States Department of Health and Human Services (HHS). Mr. Urbanowicz served as the Senior Legal Adviser to the Secretary of Health and Human Services on Medicare, Medicaid and other pressing healthcare policy issues and was also part of the team that drafted the historic Medicare Prescription Drug Act of 2003. As Deputy General Counsel he helped direct HHS's regulatory and legal positions in areas such as Medicare and Medicaid payment policy, fraud and abuse, as well as regulatory enforcement.

Prior to his service in government, Mr. Urbanowicz was a partner in the law firm of Locke, Lord, Bissell and Liddell, LLP. He served as the Treasurer and a member of the Board of Directors of the Federation of American Hospitals.

Mr. Urbanowicz earned a bachelor's degree and a juris doctor degree from Tulane University. He is member of the Bar of the District of Columbia, the United States Supreme Court, the Louisiana Supreme Court and is a member of the American Law Institute.

http://www.alvarezandmarsal.com/en/professionals/profile.aspx?ID=2729