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

医疗之家试点评估：比较效果研究模型

• 批准号: 7943123
• 负责人: Kim Dunn Dunn
• 金额: $ 48.73万
• 依托单位: UNIVERSITY OF TEXAS HLTH SCI CTR HOUSTON
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-29 至 2012-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7943123
• 关键词: Accident and Emergency department; Address; Adopted; Adoption; Businesses; Caring; Clinical; Collaborations; Collection; Communities; Community Health Centers; Community Practice; Continuity of Patient Care; Cost Effectiveness Analysis; Data; Data Set; Databases; Deposition; Diffusion; Emergency Situation; Evaluation; Guidelines; Health; Health Care Surveys; Health Information System; Health Insurance Portability and Accountability Act; Health Services Accessibility; Healthcare Systems; Home environment; Incentives; Indigent; Insurance; Intervention; Learning; Measures; Medical; Metric; Modeling; Nature; Outcome; Patients; Pattern; Personal Health Records; Pharmacy facility; Physicians; Prevention Guidelines; Primary Care Physician; Primary Health Care; Process; Provider; Public Health; Quality of Care; Research; Research Infrastructure; Resistance; Risk; Risk Adjustment; Services; Site; Specialist; Support System; System; Technology; Testing; Treatment Effectiveness; Uninsured; Visit; base; billing data; clinical data warehouse; community setting; comparative effectiveness; compare effectiveness; compliance behavior; cost; cost effectiveness; data management; data sharing; effectiveness research; electronic data; evidence base; experience; financial incentive; health care delivery; health record; hospital laboratories; medical specialties; open source; payment; programs; public health relevance; quality assurance; safety net

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

描述（由申请人提供）：利用学术健康中心与社区组织或社区研究网络之间的合作，将 CER 引入社区环境的试点/示范项目。为了将比较有效性研究（CER）嵌入到社区实践中，我们必须考虑当前处于危机中的美国医疗保健系统，特别是初级保健。即使对于那些有保险的人来说，该系统也是支离破碎、成本日益增加、难以访问和导航、服务重复、无法将患者、初级保健医生和专家联系起来，也不能确保特定患者遵循治疗和预防指南。人们期望他们的初级保健医生成为他们获得医疗保健的渠道，并确保他们在系统内接受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，也没有报酬来协调护理。这导致急诊室作为护理费用最高的场所，成为未参保和参保患者初级护理问题的主要场所，也是贫困专业护理的门户。目前还没有一种商业模式来支持必要的服务和技术支持的流程，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支付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进行严格的评估。 Medical Home 模型基于我们构建的电子数据基础设施，使医生能够协调护理、评估所提供护理的质量并参与质量改进计划。此外，该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措施，即您的医生计划医疗之家系统 (YDP-MHS)，克服了实施综合连续性护理模式的三个关键障碍，提供高质量的护理。第一个是健康信息系统基础设施，用于收集各个护理领域（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) 制定了医疗之家标准，但没有提供支持其快速、大规模实施的健康信息系统基础设施。我们开发了一种健康信息交换方法，作为 YDP-MHS 的一部分，跨护理孤岛收集信息。该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。第二个是医生收集护理质量数据和采用质量改进指南的障碍。医生常常认为质量结果比较不准确，因为他们依赖于计费数据并且没有充分调整风险。 YDP-MHS 支持在医生实践中实施 NCQA 标准，并让医生参与收集护理质量数据和改善结果的举措。第三个障碍是医生协调护理和收集护理质量数据的支付模式。私人和公共保险付款人已同意支付私人和安全网医生参与 YDP-MHS 的奖励。该示范试点提供了将比较有效性研究基础设施嵌入社区环境的机会。在多达 50 个初级保健实践中进行概念技术证明 目标 1：评估您的医生计划医疗家庭系统 (YDP-MHS) 对可避免的急诊中心就诊的影响，以解决安全网和私人患者的初级保健问题。目标 2：使用医生消费者评估和医疗保健调查来评估 YDP-MHS 对患者的医疗保健系统体验的影响。目标 3：与医生一起制定指标并进行现场测试，以比较医生治疗模式对临床指标的有效性，同时纳入患者依从性和风险调整因素的衡量标准。 YDP-MHS 的成本效益分析目标 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。 YDP-MHS 的传播目标 1：根据 YDP-MHS 社区模型的经验教训，制定扩展计划。 公共卫生相关性：我们的目标是评估医疗之家模式的快速实施的成本、患者接受度、医生接受度以及对护理质量指标的影响。该模型由高度可扩展的开源技术堆栈支持。医生采用的较短实施时间和用于确保质量的数据管理的经济激励足以获得初级保健医生的广泛接受。我们相信，医疗之家/健康信息交换策略的方法将实现影响公共健康的四件事：首先，我们计划克服建立健康信息交换/社区临床数据仓库以在竞争群体之间共享数据的阻力。然而，由于 HIPAA，患者有权获取其健康信息。鉴于在我们的模型中，他们指定其医疗家庭医生作为其个人记录的共同管理者，YDP-MHS 组织将数据“存入”患者的质量健康记录中，该记录结合了个人健康记录和健康信息交换，从而提高了可用于分析的患者数据的完整性。其次，不会对所有与医疗保健系统接触的患者进行常规收集或分析结果数据和接触数据。我们将获得如何定义流程以确保在所有重大遭遇中收集数据的经验，包括对其进行风险调整以进行分析的能力。第三，我们认为，这些付款人将出现的财务模型对于定义更广泛的付款人采用以扩大医疗之家模式非常重要。第四，我们将拥有一个数据集来比较安全网和私人患者、治疗和有效性，用于社区环境中的比较有效性研究