A Medical Home Pilot Evaluation: A Model for Comparative Effectiveness Research

描述（由申请人提供）：试点/示范项目，利用学术卫生中心与社区组织或社区研究网络之间的合作，将CER带入社区环境。为了将比较有效性研究（CER）纳入社区实践，我们必须考虑目前处于危机中的美国医疗保健系统，特别是初级保健。即使对那些有保险的人来说，该系统也是碎片化的，成本越来越高，难以获取和导航，服务重复，不能将患者、初级保健医生和专家联系起来，也不能确保对特定患者遵循治疗和预防指南。人们希望他们的初级保健医生是他们获得医疗保健的途径，并确保他们在系统内获得的护理是基于证据的、具有成本效益的、协调的和安全的。不幸的是，初级保健提供者没有适当的系统，也没有得到协调护理的报酬。这导致急诊室，这个最昂贵的护理场所，成为无保险和有保险患者初级保健问题的主要场所，也是获得贫困专科护理的门户。目前还没有一种商业模式来支持必要的服务和技术支持流程，以确保患者拥有一个负责任的医疗保健服务系统。为了解决这些问题，我们建议在社区环境中试点医疗之家干预措施。医疗之家模式被所有主要临床和付款人组织视为改革护理的关键组成部分，尽管迄今为止，对医疗之家模式几乎没有严格的评估。医疗之家模型基于我们建立的电子数据基础设施，该基础设施允许医生协调护理，评估所提供的护理质量，并参与质量改进计划。此外，这种数据基础设施为开展基于社区的比较有效性研究并产生影响提供了机会。我们提出的医疗之家干预，你的医生计划医疗之家系统（YDP-MHS），克服了实施提供高质量护理的综合连续性护理模式的三个关键障碍。第一个是卫生信息系统基础设施，用于收集各个保健部门（初级保健医生、专科医生、医院、实验室、药房等）的信息。国家质量保证委员会（NCQA）有医疗之家的标准，但没有提供支持其快速、大规模实施的卫生信息系统基础设施。我们制定了一种卫生信息交换方法，作为YDP-MHS的一部分，在各个保健领域收集信息。这种数据库基础设施也构成了基于社区的比较有效性研究的基础。第二是医生收集护理质量数据和采用质量改进指南的障碍。医生经常觉得质量结果的比较是不准确的，因为他们依赖于账单数据，没有充分调整风险。YDP-MHS支持NCQA标准在医生实践中的实施，并让医生参与收集护理数据质量和改善结果的举措。第三个障碍是医生协调护理和收集护理数据质量的支付模式。私人和公共保险支付者同意支付私人和安全网医生参与YDP-MHS的奖励。这一示范试点提供了将比较有效的研究基础设施纳入社区环境的机会。目标1：评估你的医生计划医疗家庭系统（YDP-MHS）对可避免的急诊中心访问的影响，以解决安全网和私人患者的初级保健问题。目标2：使用医师和医疗保健调查的消费者评估评估YDP-MHS对患者医疗保健系统体验的影响。目标3：与医生一起开发和现场测试指标，以比较医生治疗模式在临床指标上的有效性，同时纳入患者依从性和风险调整因素的措施。目标1：通过比较干预前后的护理成本和结果，开发和测试YDP-MHS干预的成本效益模型。目标1：根据YDP-MHS社区模式的经验教训，制定扩展计划。

DESCRIPTION (provided by applicant): Pilot/demonstration projects using collaborations between academic health centers and community-based organizations or community-based research networks that bring CER into community settings. To embed comparative effectiveness research (CER) into community practice, we must consider the current US healthcare system which is in crisis, particularly primary care. Even for those with insurance, the system is fragmented, increasingly costly, difficult to access and navigate, duplicates services, does not connect patients, primary care physicians, and specialists, nor assures treatment and prevention guidelines are followed for a given patient. People expect their primary care physician to be their point of access to healthcare and to assure that the care they receive within the system is evidence-based, cost-effective, coordinated, and safe. Unfortunately, primary care providers do not have the systems in place and are not paid to coordinate care. This results in emergency rooms, the most costly sites for care, being a major site for primary care problems for both uninsured and insured patients and a portal of access for indigent specialty care. There has not been a business model to support the necessary services and technology-supported processes to assure a patient has an accountable healthcare delivery system. To address these issues, we propose to pilot a Medical Home intervention in a community-based setting. The Medical Home model is seen as a key component for reforming care by all major clinical and payer organizations, although to date, there has been little rigorous evaluation of the medical home model. The Medical Home model is based on an electronic data infrastructure that we have built that allows physicians to coordinate care, evaluate the quality of the care provided, and participate in quality improvement initiatives. In addition, this data infrastructure provides the opportunity for community based comparative effectiveness research to be carried out and to have an impact. The Medical Home intervention we propose, the Your Doctor Program Medical Home System (YDP-MHS), overcomes three key barriers to the implementation of an integrated continuity of care model providing high quality care. The first is a health information system infrastructure for collecting information across the silos of care (primary care physician, specialist, hospital, laboratory, pharmacy, et cet.). The National Commission on Quality Assurance (NCQA) has standards for the Medical Home but does not provide a health information system infrastructure that supports its rapid, large scale implementation. We have developed an approach for a Health Information Exchange that collects information across the silos of care as part of the YDP-MHS. This data bases infrastructure also forms the basis for community based comparative effectiveness research. The second is the barriers to physician collecting quality of care data and adopting guidelines for quality improvement. Physicians often feel quality outcomes comparisons are inaccurate because they rely on billing data and do not adequately adjust for risk. The YDP-MHS supports the implementation of the NCQA standards in a physician's practice and engages physicians in collecting quality of care data and in outcomes improvement initiatives. The third barrier is payment models for physicians to coordinate care and collect quality of care data. Private and public insurance payers have agreed to pay private and safety net physicians' incentives for participation in the YDP-MHS. This demonstration pilot offers the opportunity for embedding a comparative effectiveness research infrastructure into a community setting. Technical proof of concept in up to fifty primary care practices Aim 1: Assess Your Doctor Program Medical Home System (YDP-MHS) impact on avoidable emergency center visits for primary care problems for safety net and private patients. Aim 2: Assess the YDP-MHS impact on the patient's experience of the health care system using the Consumer Assessment of Physicians and Healthcare Survey. Aim 3: Develop and field test with physicians the metrics to compare the effectiveness of physician treatment patterns on clinical indicators while incorporating measures for patient adherence and risk adjustment factors. Cost-effectiveness analysis of YDP-MHS Aim 1: Develop and test a cost-effectiveness model of the YDP-MHS intervention by comparing the costs of care and outcomes before and after the intervention. Diffusion of YDP-MHS Aim 1: Based on lessons learned with the YDP-MHS community model, develop an expansion plan. PUBLIC HEALTH RELEVANCE: Our aims are to evaluate a rapid implementation of a medical home model on costs, patient acceptance, doctor acceptance, and impact on quality of care indicators. The model is supported by an open source technology stack that is highly scalable. The short implementation timeframe for physician adoption and the financial incentives for data management to assure quality are of a sufficient nature to gain widespread acceptance by primary care physicians. We believe that the approach with the medical home / health information exchange strategy will accomplish four things that will impact public health: First, we plan to overcome resistance in building health information exchanges / community clinical data warehouses to share data among competing groups. However, because of HIPAA, patients have a right to have access to their health information. Given that within our model, they have designated their medical home physician as the co-manager of their personal record, the YDP-MHS organization "deposits" the data into the patient's Quality Health Record that combines the Personal Health Record and the Health Information Exchange, thus increasing the completeness of patient data available for analysis. Second, outcomes data and encounter data is not routinely collected or analyzed on all patient encounters with the healthcare system. We will be gaining experience on how to define processes to assure its collection on all major encounters, including the ability to risk adjust it for analysis. Third, we believe the financial models that will emerge with these payers will be important for defining broader payer adoption for expanding the medical home model. Fourth, we will have a data set to compare safety net and private patients, treatments, and effectiveness to be used for comparative effectiveness research in community settings