A Consensus Operational Definition of Patient-Centered - CiteSeerX

A Consensus Operational Definition of Patient-Centered Medical Home (PCMH) Also known as Health Care Home A joint product of the University of Minnesota and the Institute for Clinical Systems Improvement (ICSI) CJ Peek, PhD and Gary Oftedahl, MD December 17, 2010

Contents Abstract.............................................................................................................................................................................3 Aim statement — an operational definition or archetype and commitment to deliver it................................................4 The product — a specification of PCMH or health care home — an operational definition: • A paradigm case of health care home — a brief overview....................................................................................6 (“If there ever was health care home in action, this is it!”) • The fully stated paradigm case..............................................................................................................................7 (“These are required for care delivery to count as a genuine health care home — with room for local tailoring of method and ‘wiggle room’ on requirements”) • Parameters of health care home practice.............................................................................................................13 (HCH practice development from early-stage implementation to fully realized aspiration) References........................................................................................................................................................................17 Appendices 1. Why create an operational definition for Health Care Home / PCMH—desired outcomes...............................19 2. About the method: paradigm case formulation and parametric analysis............................................................21 3. Creating summarized versions of this work for a range of practical purposes...................................................22 4. About the need for consistent concepts, lexicons, archetypes, definitions in new fields.....................................23

Creators and contributors Participants spoke for themselves as implementers rather than as representatives of their organizations. A. The Health Care Home / PCMH definition or archetype core group (alphabetically) Hunt Blair Marilyn Follen, RN, MSN Tom Graf, MD David Labby, MD Lisa Letourneau, MD, MPH Jeff Schiff, MD Robert Stroebel, MD Beth Waterman, RN, MBA Gary Oftedahl, MD (sponsor, facilitator) C.J. Peek, PhD (facilitator, writer)

Vermont Division of Health Care Reform Marshfield Clinic, Wisconsin Geisinger Health System, Pennsylvania CareOregon Quality Counts, Maine Minnesota Department of Human Services Mayo Clinic, Minnesota HealthPartners Medical Group, Minnesota ICSI Dept. of Family Medicine & Community Health, University of Minnesota

B. Health Care Home / PCMH definition “second ring” contributors (alphabetically) Macaran Baird, MD, MS Michael Barr, MD Thomas Bodenheimer, MD Frank deGruy, MD Michael Erikson Wayne Katon, MD Rodger Kessler, PhD Kurt Stange, MD Jurgen Unutzer, MD

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University of Minnesota American College of Physicians University of California, San Francisco University of Colorado Group Health Cooperative of Puget Sound University of Washington University of Vermont Case Western Reserve University University of Washington

A co n s e n s u s o p e r at i o na l d e f i n i t i o n o f P C MH / H e a l t h C a r e H o m e

Abstract Hopes are high that the Patient-Centered Medical Home (PCMH) or Health Care Home will improve quality and patient experience while significantly bending the cost curve (when implemented on a meaningful scale). But the field has no agreed-upon operational or functional definition to guide widespread implementation and performance measurement, even with the important NCQA criteria in place. This is undermining understanding among implementers of exactly what has to be implemented and is likely undermining the concept of PCMH itself. A consensus operational definition for PCMH among a national group of 17 implementers was created that consists of 1) an “archetype” or paradigm case (nine highly annotated clauses that describe essential functionalities of PCMH) and 2) fourteen specified parameters (ways that one implementation might legitimately be different than another) based on level of program development or maturity. The goal was create an operational definition useful to implementers, researchers, payers, and policymakers — a promise to deliver specifics — knowing that the definition will evolve. A core group of eight PCMH implementers was drawn from four state-level public initiatives and four large private provider groups. A second ring of nine contributors systematically broadened, deepened, and sharpened the product. Published methods for creating definitions in complex subject matters were employed.

Main headings for PCMH archetype / operational definition Paradigm Case Clauses 0. P atients/citizens identifying a primary care practitioner and team 1. R outinely acting from a patient-centered, whole- person orientation 2. A iming for population health outcomes 3. Through a practice team tailored to needs of each patient and situation 4. Carrying out practice-based care coordination 5. Coordinating with the healthcare neighborhood of other teams and community 6. W ith patients actively participating in quality improvement and practice development 7. Demonstrating capacity for continuous learning and improvement 8. Supported by a sustainable business model and leadership alignment 9. Accountable to achieving a set of clinical, experience and financial outcomes

Parameters 1. Level of patient-centered, whole-person care 2. Level of population orientation 3. Range of available team expertise 4. Level of practice-based care coordination across time and space 5. Level of care coordination across the healthcare neighborhood 6. Level of patient engagement/shared decision-making 7. Level of patient involvement in shaping the practice 8. Ability to collect and use practice data 9. Ability to learn from other practices 10. L evel of leadership/administrative alignment 11. Level of operational reliability/consistency 12. Sustainability of the business model 13. Level of program development/maturity 14. B readth and depth of outcomes reported

The main findings to date are: 1. It is feasible to create a consensus operational definition among a reasonably large group of recognized implementers using these methods. 2. Pre-release response indicates that this is useful in being clearer about essential PCMH functions to be implemented and to compare the level of development across practices. More will be learned about how it helps or not after broader circulation and application. 3. Many people initially recoil at dense operational definitions such as this. But implementers often find this level of specification a relief, even if like reading an engineering or architectural manual. Implications of this work: 1. It may help meet a growing need for a shared operational definition of PCMH / health care home if the concept is to be implemented and measured on a meaningful scale. Similar awareness is growing in emerging fields such as palliative care, collaborative care, and shared decision-making. 2. It may help policymakers, patients, and payers understand “health care home in action” more consistently, form more specific expectations, and become clearer on policies needed to sustain it. 3. Specified functional components in this definition may facilitate asking consistently understood measurement and research questions for health care home on a national rather than only local scale. (See appendices for more on why and how to do this project)

© 2010 Un i ve r si t y o f M i n n e s o t a an d In s t i t u te f o r C li n i c a l Sy s te m s Im p r ove m e n t

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Aim Statement: Health Care Home Archetype / Operational Definition (primary care version) The operational definition that follows the “Aim” statement below outlines what is meant by primary care “health care home” or “patient-centered medical home”* in enough detail to reveal the archetype or fundamental pattern and a developmental path toward its full realization. *The term “health care home” is used in this document and is synonymous with “patient-centered medical home” and “advanced primary care”. These are different terms for the same concept.

Aim: This specification of health care home is offered as more than a path toward incremental improvements in quality, experience or clinical outcomes. Instead, the aim of this work is to specify in much more detail than usual the means to a critically important end for Health Care Home: Reversing the dangerous cost curve in healthcare while improving quality of care and experience. With increasingly universalized access provided through federal health reform comes accountability for quality and cost*. Everyone across the political spectrum is arguing that we cannot afford the system we have and have now expanded, that it will bankrupt the economy, and that fundamental changes in cost and quality have to occur — and occur in the near term, not the long term. That is, healthcare transformation cannot aim only at incremental gains in clinical outcomes and patient or provider experience that are “statistically significant” but socially and financially insignificant. Without bending the cost curve, health care home “transformation” is not transformation, even if “good to have”. To become a transformative model of care delivery, health care home must make a significant dent in the cost trend even more than make another incremental gain in quality and experience. Principles and values that in ordinary times are associated only with intrinsically valued ends, now also become means to achieving the affordability that is needed to prevent collapse. • Patient centeredness is also a means to better health outcomes and reduced waste through building a sufficiently trusting and supportive environment that patients will choose wisely among alternatives and prefer (without being pressured or controlled) not to waste system resources. • Patient engagement is also a means for persons to make thoughtful choices on treatments and behaviors associated with getting the most from their own efforts and the healthcare system along with doing their part to ensure affordability if they are to continue to have healthcare at all. • Effective teams are a means to higher quality care at less total cost, not only provider satisfaction. • Care coordination is also a means to reducing waste by doing things right the first time, not only improving patient experience • Health care home is a means for more reliable, efficient, and effective primary care, not only a set of professional values and principles for “how we want to be in the world” While all these still carry intrinsic value as ends in themselves, their value at this moment in history is greatly magnified by their ability to improve quality while bending the cost curve. *See Cutler (2010) for more on how health care reform must bend the cost curve

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The need for health care home to “bend the cost curve” should not be misunderstood here as cover for going back to familiar and unpopular methods that merely impose restrictions on care such as lock-ins to medical homes and referral gate-keeping. If primary care providers are seen again merely as gatekeepers, they will not be seen as (or feel like) advocates and helpers. Health care home aims to put patient health and experience first, but at same time asks providers and patients to be stewards of resources on behalf of all of us. We can indeed improve patient experience and health outcomes while improving resource stewardship. The specification or operational definition of health care home that follows is a positive formulation of functions to accomplish that. It is the relationship between the doctor and the patient in the health care home that creates the opportunity for improved stewardship — not an action (and reaction) by either one alone. A commitment to deliver: The specification of health care home offered here responds directly to the aim described above. It is proposed as... 1. A commitment to deliver (with a developmental path), not just another theoretical model or certification method. 2. A new social contract between primary care and society (with enough detail on what the practice really looks like that it is more than a lofty statement of principles easily bent to your own habits or too easily seen as “we already do that”.) 3. A public statement on the specifics primary care agrees to be held accountable for — practice actions and performance measures — accountabilities for a primary care health care home in context of the larger concept of “accountable care organizations”. 4. In keeping with the aim of bending the cost curve, a commitment for primary care taking accountability for cost, quality, and experience outcomes in a way that every investor or purchaser will want to understand as a reasonable return on investment and as a means to bending the cost curve. 5. A public statement of what persons as citizens and patients can expect and are invited to embrace by way of doing their part to make the best use of the health care system and save themselves from the relentless cost curve and challenges with quality. Annotation: This is a revised social contract with patients, not only between providers and payers — a social contract that involves shared decisionmaking and building a level of trust such that you don’t have to just “seek all available treatments” as a default or the only way to ensure “getting care for me and my family”. This social contract is proposed as a “we” statement of common interest among citizenry balanced of course with “I” statements among consumers wanting to get what they pay for and need or want at any given moment.

We believe that the health care home specification on the following pages answers a call for: 1. “Accountable primary care” to address the impending financial crisis of affordability in healthcare that threatens to leave more and more citizens without care — or units of government bankrupt — even as health reform offers increasingly universalized access, and 2. Improving the value of care to our patients while providing a clear enough role for them in order to experience this value.


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A Paradigm Case of Health Care Home: A brief overview This thumbnail is spelled out with clarifying annotations on pages 6–11

0. Patients / citizens identifying and accessing a primary care practitioner and team as first contact for a new health concern or ongoing health/illness needs Goal: Everyone has identified with (or can identify with) a health care home practitioner and team. 1. Routinely acting from a patient-centered (hence whole-person) orientation Goal: The scope of primary care entails not only biomedical care, but creation of continuous healing relationships that address health behaviors and mental health /substance abuse dimensions of care and health and take into account social realities and concerns. 2. Aiming for population health outcomes Goal: An effect on the population, not just small pockets or segments of it. 3. Through a practice team tailored to the needs of each patient and situation Goal: To produce a broad range of outcomes, patient by patient, for which no one provider or patient are likely to achieve on their own. 4. Carrying out practice-based care coordination / care management Goal: Personal care plans that are clear, comprehensive, integrated, and practical — formed with patients engaged, changed as the need arises, responsive to both evidence and patient preferences, and existing as a physical / electronic document. 5. Coordinating with the “health care neighborhood” of other teams, practices, and community resources shaped around the needs of specific patients Goal: Keeping the patient’s care plan coordinated with, reinforcing, reinforced by, and expanded by care or support taking place in other venues in other ways. 6. With patients actively participating in QI and practice development functions — co-creating the practice and shaping its performance Goal: Health care home goals, operations, and habits are truly informed and shaped by the patient perspective. 7. Demonstrating capacity for continuous learning and practice improvement Goal: Organizations and practices intentionally improve themselves and learn from others. 8. Supported by a sustainable business model and administrative / leadership alignment. Goal: Health care home practice model is sustainable within large or small organizations, with appropriately aligned incentives, with any tradeoffs between incentives managed, and without recourse to grants or other temporary financial infusions. 9. A ccountable to achieving a specific set of clinical, experience, and financial outcomes appropriate to the population under the care of the practice. Goal: Achievements in care, patient experience, affordability, and provider experience including ability to keep pace with rapid development and change.

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Health Care Home Archetype / operational definition (primary care version) What follows is a detailed, spelled-out account for use as a fine-grained guide to implementation. Simpler derivatives and tools will be created from this for other purposes.

0. Patients / citizens identifying and accessing a primary care practitioner and team as first contact for a new health concern or ongoing health/illness needs Goal: Everyone has identified with (or can identify with) a health care home practitioner and team. Annotation: For some patients, the identified health care home may be situated other than in primary care, e.g, a health care home suited for serious and persistent mental illness augmented to include primary care medical functions; or a health care home for serious, rare or highly specialized diseases. Annotation: The term “health care home” as used here is synonymous with “patient-centered medical home” and “advanced primary care”. These are different locutions for essentially the same concept but “health care home” is used here because for some, including the State of Minnesota, the term is regarded as focused more broadly on health rather than medical systems. We recognize however that many people use the traditional term “medical home” such as NCQA and other states such as Vermont for whom “medical home” is part of legislation or other official language.

1. Routinely acting from a patient-centered (hence whole-person) orientation Goal: The scope of a primary care person-centered health care home entails biomedical care, addressing health behaviors and mental health / substance abuse dimensions of care and health, taking into account social realities and concerns, and doing so through creation of healing relationships. Annotation: “Healing relationship”: Valuing — in encounter (nonjudgmental stance and personal presence); appreciating power — in encounter and over time (partnering, education, pushing); and abiding — over time (accessibility, presence for major health concerns, commitment to not give up, caring actions). From Scott, Cohen, DiCicco-Bloom, Miller, Stange, & Crabtree (2008)

A. Person- and family-centered (rather than only disease centered); with continuity over time; comprehensive — encompassing chronic care, acute care, and prevention; through healing relationships. Annotations: “Patient-centered”

1. Enabling providers to reliably meet the needs and preferences of patients, and fully informed, shared decision-making. This includes attention to person not only disease; finding common ground on what the problem is and its management; tailoring the team to specific patient needs, systems and schedules to meet patient, not only provider needs; tailoring care and interactions to the patient’s individual needs, values, preferences and family / cultural context; involving interested patients in designing the practice and its performance (IHI emerging work, 2010).

2. E nabling patient behaviors that re-orient care toward patient-centeredness. This is “patient engagement”, defined as “actions individuals must take to obtain the greatest benefit from the health care services available to them” (Gruman et al 2009; Center for Advancing Health, 2010). This focuses on the behaviors of individuals that are critical to health outcomes rather than the actions of professionals or institutions. Domains include finding safe decent care from among the alternatives; communication with professionals; organizing and paying for health care; participation in treatment decisions and treatment; promoting health knowledge, health behaviors and preventive care; planning for end-of-life. In this view, “engagement” is an active inquiry and set of behaviors by individuals not merely “compliance” (Gruman, 2010).

B. Includes behavior change aspects of health and healthcare — patient self-management & responsibility; C. Includes care of mental health / behavioral health / chemical dependency within the scope of a primary care health care home. Annotation: “Within the scope” means that mental health and behavioral health (used interchangeably) and chemical dependency are addressed as another set of conditions and situations already accepted as within the scope of primary care. This does not mean that primary care health care homes expand their scope to become specialty mental health or substance abuse clinics. 1C is a reminder that primary care health care homes need to do justice to MH / CD presentations (as they do with common biomedical conditions and prevention) as a normal part of their work. An example of doing justice might be the readiness and capacity to notice or screen for these conditions, build relationships with specialists in these areas, treat many common situations within the practice, and address the interactions of mental health & biomedical conditions.


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2. Aiming for population health outcomes Goal: An effect on the population not just small pockets or segments of it A. Population outcomes for the entire active practice panel at a minimum (rather than one or two diseases, one or two age groups, or only “high risk” or “complex”). Annotations: The aim in 2A is central to health care home, but achieving it entails overcoming technical challenges: 1. A definition of a “panel” that can be identified for each practice. The word “active” is a step in that direction. Some health care homes may consider patients’ families as part of the panel if they are the unit of relationship or service.

2. Few metrics are sufficiently cross-cutting to encompass a practice’s entire active population. Therefore, the expectation that a practice will affect each and every individual in the panel — from the healthy 17 year old to the 90+ year old — and that there are sufficient patients in each category to warrant a population-oriented focus asks a great deal of current or future systems. Some argue for targeting 3 or 4 large and meaningful subpopulations for which tracking and sufficient numbers is already available. But health care home aspires to whole population effects & scope, so 2A remains as an aspiration.

B. Aspiring to being part of achieving population outcomes on larger scales, such as for the panel of an entire organization of multiple practices, a geographical area, or region. Annotations: The aim in 2B is important to health care home, but achieving it entails overcoming challenges:

1. F or different populations at different levels, process and outcome measures require a clearly defined population ‘denominator’ accepted by providers. e.g. the PCP in charge of a panel, a clinic, a medical group, a health plan; or a public health department looking at an entire region or state. This requires the capacity to define, capture, and track key outcomes on the entire population at each level and to aggregate them for larger organizations.

2. The success of a particular health care home is judged based on the local clinic ‘denominator’ of patients, and the success of health care homes as an approach to care in a region is judged based on the larger ‘denominator” of patients.

3. Although this aspiration is a significant challenge, it is core to being successful in an “accountable care organization” model and essential to “bending the cost curve” and providing a meaningful-scale improvement in value to patients.

3. Through a practice team tailored to the needs of each patient and situation Goal: To produce a broad range of outcomes, patient by patient, that no one provider and patient are likely to achieve on their own

Annotations: Team

1. A team has specific tasks that require the interdependent and collaborative efforts of its members. (Wise et al, 1974 as cited by Bodenheimer, 2007). Outcomes commonly desired from teams: clinical outcomes superior to “usual care”, conservation of expensive physician or other clinician labor, and reduced clinician workload on activities that could be done by others (Bodenheimer, 2007)

2. A small interdependent team defined at the level of each patient may be referred to as a “clinical microsystem” that forms to meet particular patient and family needs — typically led by a physician or advanced practice provider with some combination of team members such as nursing, social work, behavioral health, pharmacist, physical therapist or others. This microsystem changes as the needs of the patient and family shift over time even as its members often remain embedded in a larger organization or system (IHI, 2010; Bodenheimer & Laing, 2007).

A. With a range of differentiated expertise and role functions available to draw from — so team can be defined at the level of each patient. • Health care home team expertise in primary care of acute, chronic and preventive care, including care coordination, health behavior change and mental health / substance abuse dimensions of the total care of patients. This includes team members routinely available plus other team members with less frequently needed role functions available as required by specific patient needs. Annotation: The NCQA proposed medical home revisions for 2011 include a requirement that one of three important conditions identified by the practice must be a condition related to unhealthy behaviors or a mental health or substance abuse condition. (PCMH 2011 draft standards)

• With patients and families considered part of the team Annotation: Patient and family roles on team include at least: Being a participant in a healing relationship; providing information on needs, preferences, values, and priorities used in shared decision-making and customizing care; and being the source of control (from IHI patient-centered care charter, 2005).

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B. With specific team members — and clear roles — actually identified and organized as a team to suit the needs of each patient. • Appropriate team members are assembled as needed for specific persons, situations, or populations — including appropriate patient engagement (Center for Advancing Health, 2010). • Composition and function of teams will change according to the constellation of active problems and resources needed for those problems. • Teams organized around the needs of specific patients are collectively responsible for continuity of care and healing relationships with those patients and families. C. Working in a common physical or virtual space that facilitates collaborative relationships, communication, and workflows. Virtual spaces must substantively achieve the goals and characteristics of an on-site presence when it comes to the patient’s understanding of team roles, shared goals, the plan of care, and communication and coordination. Annotations: Virtual space

1. S ome team functions in some health care home contexts may not be feasibly brought on site, even if routinely needed, e.g. behavioral health or other essential kinds of providers in rural areas. A virtual space that employs telehealth may help distant providers join the “common space” in a way that substantively preserves the most important aspects of on-site presence such as communication and coordination. This is an increasingly used and accepted method for extending the “common space” for teams.

2. Some health care home functions might be performed by entities acting as part of the team outside the health care home even if overall coordination takes place within it. Examples might include a workplace-based risk assessment or health promotion program or immunizations done through partnership with a public health clinic, where work is coordinated with, but not done by the health care home team.

D. With differentiated team leadership roles • A clinician practitioner leader of the team (and recognized by the patient as such) who is responsible for clinical care, clinical team composition for each patient, and developing the healing relationship based on the whole person. Annotation: “Whenever possible, the needs and preferences of every patient should be met by the health care professional with the most appropriate skills and training to provide the necessary care. Patients with complex problems, multiple diagnoses, or difficult management challenges will typically be best served by physicians working with a team of health care professionals that may include nurse practitioners and other non-physician clinicians” (from ACP Policy Report: Nurse Practitioners in Primary Care, 2010). This statement says “typically best served by physicians working with a team... “which leaves room for primary care health care home clinical team leaders to be nurse practitioners or physician assistants.

• A team organizer / facilitator / trainer who is responsible for establishing and maintaining clear enough role and competency descriptions, facilitating teamwork / collaborative practice among team members, and effectively structuring team conference time. Annotation: People working together qualify as a team only by demonstrating actual teamwork. Factors identified with performance include good leadership, clear division of labor, training in roles and in team functioning, team- supporting policies of the organization. Ongoing investment is required: training, creation of protocols that define tasks and who will do them, adoption of team rules including decision-making and communication, and granting protected, non-patient-care time for team meetings. (paraphrased from Bodenheimer, 2007). Moreover, positive practice relationships are key to successful implementation of health care home (Stange et al, 2009; Stange et al, 2010)

• A systems facilitator who is responsible for shepherding the work flow, clinic and information systems to improve reliability, reduce wasted time, and reduce unwarranted variation Annotation: While the clinician practitioner leader is recognized by the patient, the team organizer / facilitator and systems facilitator need not be recognized as such by the patient, but are recognized by clinician leader and other team members.


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4. Carrying out practice-based care coordination / care management Goal: Personal care plans that are clear, comprehensive, integrated, practical — formed with patients engaged, changed as the need arises, responsive to both evidence and patient preferences, and existing as a physical / electronic document.

Annotations:

1. “ Integrated”means at least 1) integrated with other care plans internal to the practice; 2) integrated with care provided by others outside the practice; and 3) integrated with family/patient expectations. Mottos include “Fragmented care is a ‘never’ event” (Baird, 2009) and “No more ‘I don’t have the information I need’”.

2. “ Coordination is managing dependencies between activities” (Malone & Crowston, 1994). The need for care coordination (AHRQ, 2007, p 39): 1) numerous participants are typically involved in care coordination; 2) coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient’s care; 3) in order to carry out these activities in a coordinated way, each participant needs adequate knowledge about their own and others’ roles and available resources; 4) in order to manage all required patient care activities, participants rely on exchange of information; and 5) integration of care activities has the goal of facilitating appropriate delivery of health care services.

A. Practice-based care coordination / care management • In areas of acute care, preventive care, chronic care, and complex care • With continuity of relationship & proactivity — “when you are due for a clinical test or prevention screening we will remind you, reach out to you, assist in arranging this for you”. • Meeting the patient “where they are at”, not only where providers want them to be. • Whole patient coordination with community-based resources e.g., social services, schools Annotation: “Several terms have often been used synonymously or in conjunction with care coordination: collaboration, teamwork, continuity of care, disease management, case management, care management, Chronic Care Model, and care or patient navigator. As is the case with care coordination, some of these terms lack a consensus regarding their definition and use in actual practice. . . the boundaries between these terms is blurry and each has substantial overlap with care coordination” (quoted from AHRQ, 2007 p.55). No further attempt to distinguish these for purposes of the health care home archetype is made, but the following components of care coordination (from AHRQ 2007, p. 60) are suggested as a touchstone: 1) Assess patient for likely coordination challenges, 2) develop plan for coordination challenges and organize care plans, 3) identify participants in care and specify roles, 4) communicate to patients and all other participants and across all care interfaces, 4) implement the coordination interventions, 5) monitor and adjust for coordination failures, monitor outcomes and identify coordination problems that affect outcomes.

B. Patient activation / engagement in care • Patient is engaged wherever possible in negotiating goals and treatment plans — shared patient-clinician decision making and patient choice appropriate to the situation • Goal-setting for health behaviors, self-management support, and monitoring attainment of goals, and periodically reviewing progress toward goals with an eye to adjusting the plans C. Transition management — integration of care from one setting to the next • Not just “noticing transitions”, but plans to prevent fragmentation via an accessible care plan while the patient moves between sites or venues for care and across episodes of care. • With patients and families being clear on the transition plans and their part in them • With basic agreements in place with specialists, hospitals and other settings on referrals, communication, and understanding roles in care and prevention of fragmentation D. Tracking information for care coordination and transition management, such as with HIT. • To facilitate clinical communication — including with the patient and family • To facilitate access and preferred or feasible ways of keeping patient contact • To facilitate tracking, reporting, and patient safety

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5. Coordinating with the “health care neighborhood” of other teams, practices, and community resources shaped around the needs of specific patients. Goal: Keeping the patient’s plan of care coordinated with, reinforcing, reinforced by, and expanded by care or support taking place in other venues in other ways.

Annotation: Although “coordination” is becoming the standard term, gradations of this may exist such as “cooperation” (just sharing info and notifying), “coordination” (activities of separate entities made to work in step at the right times) and “collaboration” (a more intensive ‘co-laboring’ required in particularly complicated situations).

A. Coordinating with specialists (e.g. medical, surgical, or behavioral health specialists), hospitals and skilled facilities, e.g. nursing homes, rehabilitation facilities, hospice, and others B. Coordinating with social services and community resources in the wider community C. Effectively communicating and coordinating across this larger “health care neighborhood” with patients and family in the loop — and the care plan updated and responsive to current reality. Annotations: Electronic communication platforms to link the health care neighborhood 1. T his will include proactive outreach for prevention and chronic illness care via the use of e-visits, phone visits, patient portals, and other ways of connecting through electronic “non-visit” care with practitioners and other team members. Because most primary care is practiced by small groups, this capacity is not required, at this time, of all practices otherwise qualifying as health care homes.

2. Increasingly, electronic platforms are required for communication and coordination, e.g., NCQA medical home criteria, Affordable Care Act section 3502 on Community Health Teams, and internal requirements of more and more provider organizations. At some point in the not too distant future electronic communications will become a requirement for all health care homes.

D. Operating with 24 x 7 x 365 access to someone who knows, has, or can find the patient information required. 6. With patients (and often family and community) actively participating in QI and practice development functions — co-creating the practice and shaping its performance Goal: Health care home goals, operations, and habits are truly informed and shaped by patient perspective A. Employing patient team members on an ongoing basis to shape the practice and its performance, including but not limited to ensuring routine knowledge of patients’ actual experience of care — and acting on that knowledge to make ongoing improvements in the practice. B. Employing multiple ways of engagement, e.g., longitudinal membership on QI committees, focused participation in task groups or patient advisory committees, large-scale surveys of many patients or new ways with technology to engage patients, and providing a vehicle for them to connect with other patients if they wish. Annotation: A health care home might accommodate efforts by its patients as citizens of the community to identify and select health goals or problems around which to engage professionals in a citizen-led effort for improvement using concepts of Citizen Health Care (Doherty & Mendenhall, 2006).

7. Demonstrating capacity for continuous learning and practice improvement Goal: Organizations and practices intentionally improve themselves and learn from others A. Collecting routine practice-based data for QI and improvement of practice effectiveness Annotation: Use measures at the individual level within the practice to motivate change while using practice level measures for transparency of practice performance.

B. Learning from other practices — using appropriate tools, e.g. collaboratives or other methods


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8. Supported by a sustainable business model and administrative / leadership alignment. Goal: Health care home practice model is sustainable within large or small organizations, with appropriately aligned incentives, with any tradeoffs between incentives managed, and without recourse to grants or other temporary financial infusions.

Annotation: To “bend the cost curve” while improving patient care and experience on a meaningful scale, business models will have to support health care home in sustainable ways. At this moment, business models for otherwise qualified health care homes typically do not support them in sustainable fashion and all variety of “workarounds” are being used. But in the near future, all health care homes will need to be supported by sustainable business models (A-D below) to qualify as health care homes or in the end they will not be able to claim they are accomplishing the job for patients and affordability for society as a whole.

A. Alignment of purposes, incentives, and leadership between the practice and its health care home vision, and if applicable the larger organization of which the practice is a part. B. A business model enabling practices to do what it takes to achieve health care home characteristics and be accountable for the performance and outcomes required. Annotation: As stated in clause 9, performance outcomes include health, patient experience, and affordability as well as measures of internal processes that drive performance

C. A business model enabling the health care home to work for patients, e.g. through appropriate insurance benefits design and billing systems — including for non-visit health care home functions, e.g. e-visits, phone visits, group visits, and work by care managers, health coaches. D. A business model enabling team members to be rewarded professionally and financially for the effort, so that it is sustainable. 9. A ccountable to achieving a specific set of clinical, experience, and financial outcomes appropriate to the population under the care of the practice. Goal: Specific achievements for care, patient experience, affordability of care, and provider experience, including ability to keep pace with rapid development and change.

Annotation: Practice ability to keep pace with rapid development and change has been called “adaptive reserve” or “adaptive capacity” and includes capabilities such as a strong relationship system within the practice, shared leadership, and protected group reflection time (Nutting et al, 2009; Crabtree et al,2009; Heifetz et al, 2009; Stange et al, 2010)

A. Intrinsically valued outcomes of the Triple Aim: Care/health, experience, and affordability Annotation: The intention of IHI Triple Aim and Health Care Home outcomes is to go beyond the sum of disease-specific and productivity metrics to measured effects on the health of the whole person and community: functional as well as disease measures, primary care functions that contribute to patient experience (as well as care) such as, access, comprehensiveness, integration, relationship. Not all of these are equally easy to measure.

B. Measures of internal processes that drive practice performance i.e. improvement in health care home archetype or definitional clauses 1-8 (above). Annotation: As stated in clause 9, performance outcomes include health, patient experience, and affordability as well as measures of internal processes that drive performance

C. Comparison to risk-adjusted external benchmarks as available and comparable D. Public reporting of Triple Aim outcomes for the population served by the practice Annotations: Public reporting 1. P ublic reporting to CMS or states is one of the core CMS “meaningful use” objectives for electronic health records to which provider payment is tied (Blumethal & Travenny, 2010). See Hibbard & Sofaer / AHRQ (2010) for best practices on public reporting.

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2. W hile public reporting is increasingly required and done, it is neither systematic nor customary in all communities or a technically feasible option for all practices. In the near future it will become customary and required of all practices, and in the meantime each practice should create some version of what it would publicly report if that were a genuine option.


Parameters of Health Care Home Practice How practices can differ from one another along a developmental path from early-stage implementation to fully actualizing the aspirational paradigm case Parameter

Possible values of that parameter

Clauses from paradigm case that this parameter responds to Patients identifying and accessing a PC practitioner and team as first contact for a new or ongoing health/illness needs (paradigm case clause 0) Routinely acting from a patient-centered orientation (clause 1) 1. Level of patientcentered, hence whole person care *This language adapted from Stange (2009) **From Center for Advancing Health (2010)

Fundamental care*

+ Integrated care*

• Care of acute illness • Integrated across acute and chronic illness, prevention, • Proactive management mental health of chronic illness and prevention • Management of multi• Psychosocial care and health morbid conditions behavior change as part of • Addressing social and care the above complexity that interferes • Addressing patient concerns with fundamental care and fostering engagement behaviors** • Appropriate screening/ identification for the above

+ Prioritized care*

+ Healing/transcending*

• B alancing individual, family • A ccessibility, presence for and community, needs in major health concerns, choice of goals and therapies commitment to not give up, caring actions — even when • O ngoing adjustment of healing cannot be fostered plan based on interaction of biotechnical and • Fostering healing biographical, based on deep knowledge of both

Aiming for population health outcomes (clause 2) 2. Level of population orientation

Practice panel only

Multiple practice panels

City, state, or regional

Population orientation and intended Population orientation includes effects Population orientation includes effects effects limited to the active panel of the across multiple practices such as in a large across geographical regions or identified particular practice organization or a collaborative/alliance of communities multiple practices in a community

Annotation: City, state or regional population orientation is an aspiration required to succeed at “bending the cost curve” and making a difference to patients on a meaningful scale. Even with the technical challenges identifying populations described in earlier annotations, this will be required for health care home to ultimately be a successful concept. Regional population orientation and reporting already takes place in limited forms, e.g., Rhode Island Health Quality Performance Measurement and Reporting.

Through a practice team tailored to the needs of each patient and situation (clause 3) 3. Range of available care Minimum/basic team available team expertise Expertise/functions available to tailor to (To deploy selectively on the the needs of each patient basis of specific patient needs) • Biomedical care • Psychosocial care • Health behaviors and engagement behaviors • Care coordination • Integrating, prioritizing and personalizing

Basic team plus others

Extended team, add

Additional expertise/functions available • S pecialized disease-experts, i.e., specialists and educators to tailor to patient needs • S pecialized population experts • Social service/resource expertise and (e.g., children with special needs, connections occupational health, rehabilitation, • Behavior health/mental health/ substance abuse care and connections to mental health or chemical dependency) • S ocial experts, e.g., cultural, school, specialists vocational, spiritual, corrections • Expertise in common populations or problems ( e.g., pharmacy, geriatrics, women’s health, pediatrics, physical therapy)

Annotations: • This depicts functions available on the core team but not disciplines, because individuals and disciplines with that expertise likely vary from place to place. This parameter depicts an increasing range of expertise available to deploy based for specific patient needs, not an expanding checklist of disciplines. • P urely as an illustration, a basic team might consist of a doctor or nurse practitioner, nurse/MA, and care manager. Basic team plus might add social worker, patient advocate and a mental health counselor of some kind. Extended team expertise might add consulting medical or surgical specialists, palliative care, geriatrics, specialty mental health or chemical dependency care, health or disease educators and coaches, or other experts or care facilitators commonly needed for the population of that specific practice. • Members of basic team are typically together on site. As the team becomes more extended, the likelihood increases that they are not all on site, not on site much, or are linked via telehealth or other “virtual space”. Linking teams via shared information systems and care plans is needed.


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Doing practice-based care coordination / care management (clause 4) Coordinating with the “medical neighborhood” of other teams, practices, community resources shaped around needs of specific patients (clause 5) 4. Level of care coordination/ management across time and space

Practice-based care coordination— Practice-based care coordination— limited to the practice partially integrated

Full scope care coordination— fully integrated

Care management action and health information: • L imited to the clinic and one or two venues beyond the clinic and/or • L imited to a given episode of care; and/or • Intermittent after-hours coverage

Care managment action and health info: • I ntegrated across all venues of care typically used by the practice population • Longitudinally across episodes of care • 2 4x7 coverage and information availability

Care management action and health information: • L imited to the clinic and several venues beyond the clinic important to the practice population and/or • T aking place across episodes of care; and/or • Substantial after-hours coverage

Annotation: The terms care coordination and care management are used here synonymously. Practice-based care management in the health care home goes beyond implementation for only one or two population segments, e.g., disease or stage of life; a biomedical rather than biopsychosocial focus, or little capability to manage care after office hours. At the same time, practices will have a need to prioritize their care coordination efforts, particularly early in their development as health care homes that will have a meaningful-scale impact on care, experience and the “cost curve”.

5. Level of coordination across “health care neighborhood”

Medical services only

Medical services plus

Full member of health care neighborhood

A coordinated medical services model with connections to medical specialists and hospitals but limited connection to other parts of the medical neighborhood except by chance or individual provider initiative

Coordination with more than one, but not all venues and figures in the health care neighborhood. Some effort to connect and coordinate, but few concerted systems for communication and coordination

Coordination with all or almost all significant venues and figures in the health care neighborhood — using concerted systems for communication and coordination

Annotation: Examples of being coordinated across the health care neighborhood may include shared practice and communication agreements, shared care plans or information systems, shared outcomes tracking, coordination of care explicit & visible to patients, managing transitions, etc.

6. Level of patient Limited/non-systematic engagement/ activation •M eeting patients where they and shared decisionare at with mutual goal-setting making for self-management, but not systematic — mostly up to individual providers or from time to time for the same provider. • L imited non-systematic fostering of patient engagement behaviors

Partially systematized

Standard work

• A n intention along with some systems •M eeting patients where they are at. in place (partial reach and effectiveness) Mutual goal-setting and shared patient/ to ensure meeting patients where they family/clinician decision-making with are at, mutual goal-setting for selfdecision aids is fully systematized — management and choice, and shared built into routine clinical systems and decision-making behaviors. • S ome systematic fostering of patient • S ystematic fostering of patient engagement behaviors engagement behaviors

Annotations: • “Patient engagement behaviors” refers to the Center for Advancement of Health (2010) patient engagement behavior framework. • The concept of “limited / non-systematic” to “standard work” is intended to apply to small practices as well as large ones. Even one clinician supported by one staff can be more systematic or less systematic and more consistent or less consistent. This concept has less to do with the size of the “system” but the level of consistency and standardization no matter how big or small the practice. A consistent approach to giving personalized care can indeed become “systematic” within a small practice or a standard approach for a given clinician.

With patients actively participating in QI and practice development functions — co-creating the practice and shaping its performance (clause 6) 7. Level of patient involvement in shaping the practice

Involved as a consumer

Involved as a practice collaborator

Involved as a co-creator of health

Example: A sample of patients participate in focus groups on services, hours, locations, features, experience, prices — but as a customer not as a practice collaborator

Mechanisms are in place to engage a sample of patients as collaborators in the design performance monitoring, and improvement of the practice

A sample of patients may participate as practice collaborators or consumers, but are primarily “citizens” of the health care home — taking responsibility for co-creating the practice and health with other citizens and clinic providers.

Annotation: “Co-creator [or co-producer] of health” is a concept from “Citizen Health Care” (Doherty & Mendenhall, 2006)

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Demonstrating capacity for continuous learning and practice improvement (clause 7) 8. Ability to collect and use Little or none practice data for QI and Little or no routine data collected and effectiveness used for learning from experience and making decisions on quality and effectiveness, but a strong aspiration to do so

Embryonic

Mature

A starter system for collecting and using practice data for QI and making decisions on how to improve effectiveness — along with plans and starter scorecards for making it better

Routine, systematic and extensive data collection and actual use in decision making for quality & effectiveness — supported by clear plans and scorecards

Annotations: • Practice-based data are to capture not only disease care, but patient experience and whole-person and community outcomes that are sensitive to the care coordination and the integrating, prioritizing, personalizing functions. • Populations would need to be defined, eventually the whole active practice population and key sub-populations — a technical challenge.

9. Ability to learn from and Little or none with other practices Little or no contact or interest in learning from and with other practices via collaboratives, conferences, joint projects, etc, with only some awareness of this as a good idea.

Toes in the water

Mature

Beginning and limited efforts to participate with other practices in mutual learning or experimentation in areas of shared interest for practice improvement — with at least some leadership interest in pursuing this

Routine participation with other practices in various forms, with mutual learning or implementations as part of how leaders facilitate practice changes and generate new knowledge more quickly

Supported by a sustainable business model and administrative / leadership alignment (clause 8) 10. L evel of administrative/ leadership alignment

Apparent conflicts

Roughed-in

Aligned

Lots of unnamed and/or unresolved tensions between purposes, incentives, and leadership between the practice and its medical home vision, (and if applicable its larger organization)

Some alignment achieved but with ongoing work on unresolved tensions between purposes, incentives, and leadership between the practice and its medical home vision, (and if applicable, a larger organization)

Constructive balance or tension achieved between purposes, incentives, and leadership between the practice and its medical home vision, (and if applicable a larger organization); diversity of perspective and purposes adds value rather than chafes; learning incorporated into practice

Annotations: • Key leaders in a practice typically include those at local and executive levels (if applicable) and those with clinical, operational, and financial responsibilities. Having successful work relationships is key to aligning or balancing incentives. • Characteristics of successful work relationships include 1) trust to do job without unnecessary oversight; 2) diversity of world views that broadens potential solutions; 3) mindfulness of potential of new ideas; 4) sensitivity to the interrelatedness of work tasks; 5) respectful interactions / willingness to change one’s mind; 6) a varied mixture of social and task relationships; 7) communication effectively geared from rich channels (face-to-face, phone) to lean channels (emails & memos), depending on the task (Tallia, Lanham, McDaniel, & Crabtree, 2006). • Positive network of work relationships is essential to accomplish the transformational tasks of PCMH (Stangeetal, 2010).

11. L evel of operational reliability and consistency

Partially routinized

Evolving toward standard work

Standard work

Medical home clinical, operational, and teamwork processes are non-standard processes that vary substantially by clinician and are not especially reliable or consistent

Standards are set with improved reliability for some medical home processes but unwarranted variability and clinician preference remain

Whole team operates each part of the medical home system in a standard expected way that quickly reveals lapses and system errors and creates room for individualization where that is important.

Annotation: “Standard work” (a term from Lean process improvement) is defined as “work that is specified for content, sequence, timing, location and outcome”. This definition applies to clinical processes that need to be done consistently and reliably — including standard and reliable approaches to patient-centered tailoring of care. Standard work is more about being consistently effective in care processes than about rigid behaviors. “Routinized” means followed reliably in practice, not a blind adherence to ill-fitting behaviors. In Lean, a problem with a care process might be categorized as 1) a broken process — one that doesn’t produce the desired results, 2) no standard for what the process should look like in the first place, 3) the standard is not being followed, or 4) the standard is not ideal. In each case, the practice tries to bring about better and more repeatable results for patients and staff through creating and carrying out “standard work”, even for complex processes that require customization. (From Lean Healthcare Exchange; www.leanhealthcareexchange.com and IHI, 2005)


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12. Sustainability of business model

Traditional fee-for-service plus some level of bundled payment or pay for performance

Hybrid

Payment for value and outcomes

Traditional business model, e.g., FFS used to support medical home functions with modest augmentation from some forms of bundled care coordination payments or performance bonus tailored for necessary medical home activities

Significant bundled payments, program fees or other business arrangements tailored to medical home model that augments traditional FFS and P4P or performance bonus healthcare payment model

A benefits and payment system specifically designed to sustainably support all key elements of medical home team/practice function and activities (not just to support administration or the larger institution)

Annotation: “Payment for value and outcomes” applies to practices that are well-developed and mature according to the other parameters. Start- up, pilot, or otherwise immature health care home implementations cannot be paid only on value and outcomes. Payment as in the “hybrid” level will support building the infrastructure that eventually may lead to payment for value and outcomes. See also parameter 13 regarding level of expectations for outcomes depending on practice scale or maturity.

Accountable to achieving clinical, experience, and financial outcomes appropriate to the population under the care of the practice (clause 9) 13. L evel of expectation Pilot for outcomes based Limited expectations for a limited on program scale or maturity (from Davis, 2001) set of outcomes: A demonstration of feasibility or starter ”test of change”.

Project

Mainstream

Significant, but not full-scale outcomes expected: Multiple promising pilots gathered together and led visibly as a project aiming toward the mainstream.

Full scale and broad-based outcomes expected: Full scale ‘way of life’ in the practice — the way things are done, no longer a project attached to a mainstream that hasn’t changed.

14. B readth and level of outcomes measured and reported

Measure and report

Measure and report, with improvement plans in place

Measure, report, and show improvements

Measuring and reporting a set of Triple Aim outcomes and measures of internal processes that drive performance

Measuring and reporting Triple Aim and internal process measures along with plans to improve performance that are responsive to those findings

Measuring and reporting Triple Aim and internal process measures along with measured improvements that achieve a substantial portion of target outcomes — involving patients in the choice of relevant practice outcomes

Annotations: • Measures of internal processes that drive practice performance include health care home archetype clauses 1-8 in the first section of this document. Examples of internal process outcomes based on these clauses appear in the annotation on clause 9. • Ideally, outcomes are negotiated and periodically renegotiated with patients, providers, practices, and payers — with regular (e.g., semi- annual or at least annual) ‘update’ of relevant outcomes that are being tracked, that are the focus of quality improvement activities. • W hile there may be overall population-level outcomes, ideally patient-level goal attainment outcomes are an important part of the outcomes tracked. This could be facilitated through a process like ‘goal attainment scaling’ (Klosek, 2007).

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References: ACP — American College of Physicians (2009). Nurse practitioners in primary care policy monograph (www.acponline. org/advocacy/where_we_stand/policy/np_pc.pdf) AHRQ — Agency for Healthcare Research and Quality (2007). Closing the Quality Gap: A critical analysis of quality improvement strategies, Volume 7 — care coordination. AHRQ, U.S. Dept of Health and Human Services (www.ahrq.gov) Baird, MA (2009). Motto from presentation “Integrated medical and behavioral care” presented at “Bridging the Divide” conference, November 16, 2009; Burlington VT. Blumenthal, D, and Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. NEJM, July 13, 2010. NEJM.org Bodenheimer, T. (2007). Building teams in primary care: lessons learned. A report of the California HealthCare Foundation (www.chcf.org) Bodenheimer, T. & Laing, B. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine; 5:457- 461 Center for Advancing Health (2010). A new definition of patient engagement: What is engagement and why is it important? Center for Advancing Health, Washington D.C. www.chah.org. Much of this content also contained in Gruman, J., Holmes-Rovner, M., French, M., Jeffress, D., Sofaer, S., Shaller D., & Prager, D. (2010). From patient education to patient engagement: Implications for the field of patient education. Patient Education and Counseling. Vol.78, Issue 3, 350-356. Christianson, C, Hwang J., Grossman, J. (2009). The Innovator’s Prescription: A Disruptive Solution for Health Care. New York: McGraw Hill Crabtree BF, Miller WL, McDaniel RR, Stange KC, Nutting PA, Jaen CR (2009). A survivor’s guide for primary care physicians. J. Fam. Pract. Aug 2009;58(8):E1-E7. Cutler, D. (2010). How health care reform must bend the cost curve. Health Affairs, 29:1131-1135 Davis, T. (2001). From Pilot to Mainstream: Promoting Collaboration Between Mental Health and Medicine. Families, Systems, & Health, Vol 19, No. 1 Doherty, W. J., & Mendenhall, T. J. (2006). Citizen health care: A model for engaging patients, families, and communities as co-producers of health care. Families, Systems & Health, 24, 251-263. Applications including smoking, diabetes, depression, parenting, healthy child development, and the patient-centered medical home are posted at www.citizenprofessional.org. Gruman (2010). Good Behavior. Center for Advancing Health, Washington D.C. www.chah.org Gruman, J., Jeffress, D., Edgman-Levitan S., Simmons, L., & Kormos, W. (2009). Supporting patient engagement in the patient-centered medical home. Center for Advancing Health, Washington DC, www.chah.org. Heifetz R., Grashow, A., & Linksy, M. (2009). The Practice of Adaptive Leadership. Harvard Business Press, Boston MA Hibbard J, Sofaer S. (2010). Best Practices in Public Reporting No. 3: How to maximize public awareness and use of comparative quality reports through effective promotion and dissemination strategies. AHRQ Publication No. 10-0082-EF, May 2010, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pubrptguide3.htm IHI — Institute for Healthcare Improvement (2005a) Patient-centered care charter www.ihi.org/IHI/Topics/ PatientCenteredCare/PatientCenteredCareGeneral/EmergingContent/PatientCenteredCareCharter.htm IHI — Institute for Healthcare Improvement (2005b). Going Lean in Healthcare. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005. (Available on www.IHI.org) IHI — Institute for Healthcare Improvement (2010) Clinical Microsystem http://www.ihi.org/IHI/Topics/Improvement/ ImprovementMethods/Tools/ClinicalMicrosystemAssessmentTool.htm


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IHI — Inst. for Healthcare Improvement (2010). The Triple Aim. www.ihi.org/IHI/Programs/StrategicInitiatives/ TripleAim.htm Klosek, M. (2007). The use of Goal Attainment Scaling in a community health promotion initiative with seniors. BMC Geriatrics 2007, 7:16 Lean Healthcare Exchange (2010) (www.leanhealthcareexchange.com) Malone, T. W. & Crowston, K. The interdisciplinary study of coordination. ACM Computing Surveys, 1994 (March), 26 (1), 87-119. (Reprinted in G. M. Olson, T. W. Malone, and J. B. Smith (Eds.) Coordination Theory and Collaboration Technology. Erlbaum, 2001Mahwah, NJ: Malone T.W., Crowston, K.G., & Herman, G. (Eds.) Organizing Business Knowledge: The MIT Process Handbook, Cambridge, MA: MIT Press, 2003). NCQA-National Committee on Quality Assurance (2010) PCMH 2011 draft standards. http://www.ncqa.org/Portals/0/ PublicComment/Draft_Standards_PCMH.pdf Nutting, P., Miller, W., Crabtree, B., Jaen, C., Stewartm E., & Stange, K. (2009). Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Annals of Family Medicine, Vol 7, No. 3, pp 254-260 Ossorio, P.G (2006). Conceptual-Notational Devices. Chapter in: The Behavior of Persons, The Collected Works of Peter G. Ossorio, Vol V. Descriptive Psychology Press, Ann Arbor, MI Peek & ICSI (2008) — The Institute for Clinical Systems Improvement. Report on the Current State of the Art in Health Care Home. Prepared for the Minnesota Departments of Health and Human Services. Available at: www.icsi.org/health_ care_redesign_/health_care_home_/ and at www.health.state.mn.us/healthreform/homes/documents.html Scott, J., Cohen, D., DiCicco-Bloom, B., Miller, W., Stange, K., Crabtree, B. (2008). Understanding healing relationships in primary care. Annals of Family Medicine, Vol 6. No 4, pp. 315-322 Stange, KC (2009) A science of connectedness. Annals of Family Medicine, vol. 7, no. 5 September/October 2009 Stange KC, Nutting PA, Miller WL, Jaén CR, Crabtree, BF, Flocke SA, & Gill, JM (2010b). Defining and measuring the patient-centered medical home. J. Gen. Intern. Med. 2010;25(6):601-612. Stenger, R. & Devoe, J. (2010). Policy challenges in building the medical home: Do we have a shared blueprint? JABFM, May-June 2010, Vol 23, No. 3. Tallia, AF, Lanham, HJ, McDaniel, RR, & Crabtree BF (2006). Seven characteristics of successful work relationships. Family Practice Management. (www.aafp.org/fpm) Wise, H., R. Beckhard, I. Rubin, A.L. Kyte. Making Health Teams Work. (Cambridge, MA: Ballinger Publishing, 1974).

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Appendix 1 Why create a Health Care Home operational definition? Hopes are high for the Patient-Centered Medical Home (PCMH — known in some states as Health Care Home), to improve quality and patient experience while significantly bending the cost curve (when implemented on a meaningful scale). But the field has no agreed-upon operational definition to guide widespread, meaningful scale implementation and performance measurement even with the important contribution of the NCQA (2010) criteria. The PCMH concept has garnered widespread enthusiasm, but remains ambiguous when it comes to the essential core of what has to take place on the ground — real practice change — and is therefore still regarded as a buzzword by many. Moreover, different stakeholders such as primary care providers, health system administrators, insurers, payers, and policymakers understand or embrace the elements of PCMH / HCH differently, as do different states that have enacted health reform legislation (Stenger & Devoe, 2010). Researchers asked to study the effects of PCMH implementations face many different definitions, hopes, and expectations that complicate asking consistently understood and applicable research questions.

One quote on clarity of PCMH concept in practice: “What do we know about medical homes? Very little — we don’t know how to identify them, their critical components, how to build or remodel them, whether we need a contractor or not, how to finance their creation or maintenance, their impact on the Triple Aim, how patients use them . . . And we don’t really know what to measure because we don’t have a definition of the core components of medical home. . . ” Q uoting from Leif Solberg, HealthPartners Research Foundation, presenting at the Agency for Healthcare Research and Quality Annual Conference, 9/28/10: Do patient-centered medical homes lower costs and improve quality?

More players, more perspectives, and more cacophony. A transformation of the magnitude called for by health care home requires joint effort by providers, health system leaders, insurers, payers, and policymakers — no one stakeholder can do it alone. The Institute for Clinical Systems Improvement (ICSI) in Minnesota has functioned as a regional convener / catalyst since 2007 for many conversations among these public and private stakeholders, including some conversations regarding design of the Minnesota health care home program that responded to 2007 state legislation. Considerable variation in goals, language, and implementation was discovered to exist nationally and locally (Peek & ICSI, 2008 — a state commissioned study). Participants in ICSI work groups observed that conversations often move between myriad local variations on health care home and the local language used to characterize them — an observation later confirmed by Stenger & Devoe (2010). This led to a sense of cacophony — many voices saying seemingly different things — and constantly repeating questions such as those in the box at the right. Such a public self- presentation by the field does not sustain the attention of policy-makers who prefer to listen to unified voices talking about similar things using the same language.

Repeating questions encountered in conversations about health care home: •W hat are the truly required functional capabilities — core components? How would I tell if I am looking at a genuine health care home? How do I know whether to agree when someone says, “we already do that”? • I s care coordinator the same as care manager or care navigator? What is the essence of what they do? In what ways must behavioral health be part of health care home functionality? •W hat is health care home accountable for by way of outcomes — beyond certification check-offs? • H ow are we going to sustain the attention of policymakers by specifying health care home in similar language rather than being perceived as “all over the map”? • H ow will policymakers reach a clear and consistent enough understanding of health care home in actual practice to advocate for changes in business models needed to support those functions? • I mplementations will be startups at first. How can we describe a developmental path with milestones for medical home functions so that different levels of practice development or maturity can be explicitly recognized for what they are and paid for accordingly?


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Where this work came from; the initially stated desired outcomes This work (initially called “Health Care Home Archetype”) was conceived in 2009 by the ICSI National Social Network on Health Care Home, a monthly conference call of implementers from coast to coast and in Minnesota. The purpose was to learn from each other as health care home was implemented in the many states and provider groups. An ICSI goal was also to bring a more national perspective to the work in Minnesota.

“The ability to articulate the functional core of medical home in a consistent way is the ticket of admission to serious attention from policymakers and others in a position to influence the rules of the game and alter the business model for health care home”. F rom 9/12/09 notes of the ICSI National Social Network on Health Care Home

The desired outcome at the outset (Nov 2009): An operational definition or archetype for health care home that is specific enough to be useful in practice. That is... 1. Implementers, researchers, payers, patients, and policymakers will no longer be unclear or confused about what functions are entailed by the health care home when put into practice. 2. Government or philanthropic funding organizations will no longer find it difficult to see what is the same or different in health care home implementations they are being asked to fund.

“An archetype with room for local tailoring can lead to a family of applications by state or organization — all with their own variations on the archetypal features. But it is the archetype that all of us working our particular medical home implementations can come together around in a consistent way — — An archetypal operational definition to move forward at a national level as a consistently understood “movement” and locally as consistently understood developmental trajectories. . . . . . Amounts to forming a voice on behalf of an archetype rather than being experienced by others as a random chorus of voices on behalf of myriad specific implementations . . .”

3. An archetypal operational definition of core functionalities will leave room for local tailoring of methods and level of program development or maturity, so that it is easy to describe in a consistent and standard manner what is the same or different between particular health care home implementations 4. A non-controversial description of the essence of medical home will emerge (what counts as the genuine article) to which policies and business models can be suited. It will no longer be difficult for policymakers to see a consistent unified essence for the profound shift that policies and business models need to support. 5. A credible and practical group is dedicated to forming this archetype, evolving it with input from ever- widening circles of implementers, using it to implement medical home in their own contexts, and delivering a more consistent and widely heard promise to deliver the specifics outlined in the operational definition — with patients joining in and participating along with the providers.

“The archetype can help anchor business model discussions. Many conversations on “payment models” move among myriad specific features of particular medical home implementations. But what policymakers at the national level (and all of us collectively) need is to consistently articulate a health care home business model anchored in the archetypal medical home — rather than being wildly aimed at the many variations that happen to be under discussion at any given time. As Christenson points out in “Innovator’s Prescription”, a “disruptive innovation” succeeds only to the extent that its business model is also disruptive. Innovations that catch fire are not built on legacy business models. We need to be clear enough on what the health care home innovation really is at the core and then ask what “disruptive” business model it will take to support it . . .”

Some may say, “We’ve already done that — look at the Joint Principles and the NCQA criteria”. These are a great start, but focus on high-level principles, “anatomical” features or toolboxes more than on detailed, operational-level description of goals, functions, relationships, habits, and expectations for health care home in action.

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Appendix 2 About the method for creating an archetype or operational definition: Paradigm case formulation and parametric analysis Distilling an archetype from the many specific examples of health care home. The ICSI Social Network on Health Care Home generated a hypothesis that when you look at specific health care home functions (in action on the ground — not only principles and generalities) across the many states and organizations, a basic health care home pattern, a functional archetype, emerges. Such an articulation of core goals, functions and desired outcomes for medical home (regardless of whose it is) is a paradigm case that we can all agree is the functional essence or archetype. Clearly, an archetype or operational definition that would serve practical purposes across a broad range of people interested in health care home could not be created by one person or perspective alone. Doing so would increase the sense of cacophony that implementers, policymakers and researchers had noticed. Fortunately methods for defining complex subject matters that meet the requirements exist in the published literature (Ossorio, 2006). A “paradigm case formulation” is a vehicle for creating a definition that maps both similarities and differences. A “parametric analysis” builds on the paradigm case to create a specific vocabulary for how one instance of a genuine health care home might differ from another instance across town. The paradigm case and parameters amount to a set of interrelated concepts (like an extended definition) that can be used in comparing practices, setting standards, or asking research questions using a common vocabulary. Current applications of this methodology in emerging fields of healthcare include collaborative care practice, palliative care practice, health care home in action and shared patient-clinician decision making. The facilitation details for this intensive group process were devised by the first author but are beyond the scope of this report. Methodology adapted from: • Ossorio (2006) “Conceptual-Notational Devices”, a chapter in The Behavior of Persons, The Collected Works of Peter G. Ossorio, Vol 5., Descriptive Psychology Press, Ann Arbor MI. • Peek (2009) “Toward a Conceptual System for the Field of Collaborative Care: A Starter Lexicon for the Collaborative Care Research Network” (a prepublication white paper for an AHRQ-funded research conference).

Requirements: A method for creating an operational definition with standing in the field would . . . • B e consensual but analytic (a disciplined transparent process — not a political campaign) • I nvolve actual implementers and users (“native speakers” of the health care home language) • F ocus on what functionalities look like in practice (not just on principles, values, or visible ‘anatomical features’) • S pecify acceptable variations around the required archetype — so it is not a rigid prescription. • B e amenable to gathering around it an expanding circle of “owners” and contributors (not just an elite group coming up with a declaration)

Method: Paradigm case formulation and parametric analysis 1. First comes a paradigm case of health care home: An incontrovertible case of health care home practice is described in clauses. “If that’s not health care home in action, I don’t know what is!” • A ll clauses are required for a practice to count as a genuine health care home. It is not a menu from which to pick and choose. All these are required for quality and to “bend the cost curve”. • T he elements are framed to allow local tailoring of method. Annotations clarify the rationale and terms used along with any “wiggle room” in the requirements. 2. Then come parameters of health care home practice: Building on the paradigm case clauses, fundamental dimensions (parameters) articulate how health care home practices can differ from one another along a developmental path from early-stage implementation to an aspirational health care home practice. The gradations along these dimensions are intended to be descriptive and not to be read as another “certification level”.


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Appendix 3 Creating summarized versions of this work for a range of practical purposes Why this level of detail and complexity? The foregoing operational definition (using paradigm case formulation and parametric analysis) are very detailed and appear quite dense on the pages. Many people initially recoil at dense operational definitions such as this. But implementers often find this level of specification a relief, even if like reading an engineering or architectural manual. This is necessary if it is to go beyond familiar statements of value, principles and components to define these operationally in practice and cite the rationale, references, and clarify the lexicon being used. The information and distinctions offered here were distilled from many hours of conversation with the core group and second ring contributors who wish to define this concept operationally enough that it is increasingly clear just what has to take place in a practice for it to be a genuine health care home and offer a guide to practice development. Secondarily, it offers a lexicon for what things like “patient- centered”, “healing relationship”, “patient engagement” and many other terms which are often confusing to people. All this detail had to be captured and reviewed by the core group and second ring contributors before they could put their names on it. But derivative summaries and tools are also needed. Derivative summaries and tools. The health care home operational definition that appears here is more like an “engineering manual” than a “brochure”. But once these details are agreed upon as close enough to use, knowing they will evolve, handier tools and guides are necessary for people in the field and for publication. For this we propose a family of derivative documents and tools of these kinds be written and put to use: • Summaries — from which the “logic”, main points, “gestalt” or “forest” emerges from all the trees. The abstract and the one-page thumbnail paradigm case following the aim statement are examples. Other examples done in more narrative form or using visual representations can also be written to be friendly and accessible to different audiences. If summaries are effective, they will interest people in digging into the details — as summaries alone are of limited usefulness “on the ground”. • Checklists or self-assessment tools — handy self-assessments that someone in practice could use to profile their own practice according to the paradigm case clauses or level of development according to the parameters. Such tools can facilitate quickly comparing notes across practices, forming local or regional development or improvement agendas and monitoring progress. • Web-based versions — in which annotations and other levels of detail can be accessed through links in the text rather than cluttering the many pages as they do here. A version of the aim statement could be the home page that opens to the paradigm case clauses that are full of links to the details and references — with an easy navigation path back to the larger picture. • Audience-specific focused expansions — for particular audiences such as implications for policy, business models, health information technology, team development, behavioral health, or reimbursement. Any area of the paradigm case could be the focus of more specific work and development. Such derivative summaries and tools remain an IOU. But the dense “engineering” level is required before the derivatives and that is the present stage of this work. Everyone is invited to help create derivative tools!

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Appendix 4 About the need for consistent concepts, lexicons and “archetypes” in new fields Why include lexicon / conceptual development as part of forming practice development or research agendas? Questions about terms often come early in conversations intended to create research or practice-development agendas for emerging healthcare fields. For example — “Do we have a good enough shared vocabulary (set of concepts and distinctions) for asking research questions together across many practices? Do we mean similar enough things by the words we use or how we distinguish one form of practice from another for purposes of investigating their effects? Do we have a shared view of the edges of the concept we are investigating — the boundaries of the genuine article or the scope of our subject matter? If we don’t share enough of that vocabulary, we will think we are asking the same research questions, using the same distinctions, doing the same interventions, or measuring the same things — but we won’t be — and will confuse our network practices and our funding organizations...” (from Peek, 2009) In general, clearer and more consistent concepts and definition for a field are needed when: 1. Enough people are stumbling over language and what things mean — especially as encountered in practice, not only in theory or at the level of principles and values. 2. Enough people need clearer boundaries for an area X — what counts as “this is a genuine example of it” for describing to the public, setting expectations, assigning insurance benefits, certifications, or saying how something is different than “usual”. 3. People are asking, “What components are necessary for a given practice to really be X? What are the dimensions and milestones for practice improvement within these components?” 4. Researchers want to ask quality or research questions more consistently and clearly — especially in geographically distributed research or QI networks

“. . . All mature scientific or technical fields have lexicons (systems of terms and concepts) developed well enough to allow collaborative and geographically distributed scientific, engineering, or applications work to take place. These lexicons are developed for practical reasons of communication among professionals doing the real work of science and practice. Systematically related concepts have an esteemed place in the history of mature fields that we now take for granted, e.g., electrical engineering, physics, and software development. Conceptual development in these fields has enabled them to become mature sciences or technologies with associated empirical triumphs. In many cases the conceptual or pre-empirical development of these fields was done so long ago that we take it for granted and now see only the concrete empirical achievements. But it takes a generally understood system of concepts and distinctions to do good science. . .” F rom Peek (2009) and inspired by Bergner. R. (2006) An Open Letter from Isaac Newton to the Field of Psychology. Advances in Descriptive Psychology, Vol. 8., Descriptive Psychology Press, Ann Arbor MI.

5. There is a felt need to improve the consistency or reputation of an area with “outsiders”, e.g., policy-shapers, legislators, funders and others who are not living the experience as “insiders”. 6. When your field is being distorted or misunderstood by the public or subset — when practitioners themselves are inconsistent in the way they present the field to the outside world. Lexicon / conceptual development aimed at creating consistently understood research or practice development questions has been used in emerging healthcare fields such as collaborative care (behavioral health / primary care collaboration), palliative care, shared decision-making, and patient- centered medical home. The methodology employed by this author has been paradigm case formulation and parametric analysis. Ossorio (2006) “Conceptual-Notational Devices”, a chapter in The Behavior of Persons, The Collected Works of Peter G. Ossorio, Vol 5., Descriptive Psychology Press, Ann Arbor MI.


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