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

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

This summer, Hope Street Group is changing the status quo.  We are launching the first health care project of its kind, an eight-week initiative that brings together health care practitioners, industry professionals, entrepreneurs, policy-makers and members of the academic and research community to develop health care policies.  Together, we will be reinventing primary care to address resource shortages, reduce system-wide health care costs, and ensure that Americans have access to the quality health services they need most.

We are currently recruiting participants in this exciting initiative called “Policy 2.0: Using Open Innovation to Reinvent Primary Care.”  The initiative will focus on some of the most pressing, yet solvable, problems facing primary care.  If you accept this invitation, you will be able to connect your ideas with our distinguished group of advisors, including Dr Doug Henley (Executive Vice President/CEO, American Academy of Family Physicians), Peter Lee (Director of Delivery System Reform, Department of Health and Human Services, Office of Health Reform) and Dr. Bob Kocher (Special Assistant to the President, National Economic Council)  - see the full list here:  http://www.hopestreetgroup.org/docs/DOC-1781.  You will be driving research-based recommendations - designed to lead real change - that will be presented to federal and state level policy-makers, industry, and the larger health care reform community.

To help this all come together, the project will use our online platform that has been used successfully by professionals in other fields to develop policy solutions.  Hope Street Group will select participants based on their experience and expertise, so if you would like to accept this invitation please send a brief statement of interest to Diana Harris at Diana@hopestreetgroup.org by July 1, 2010.  Only a limited number of individuals can participate in the project, so do not delay.

Hope Street Group is a nonpartisan nonprofit dedicated to expanding economic opportunity for all Americans.  Our approach is simple: bring new voices to the public policy debate in innovative ways in order to develop solutions to pressing national problems.  To learn more about Hope Street Group, please visit: http://www.hopestreetgroup.org/community/healthcare and experience Policy 2.0, our customized online collaboration platform.