Coordinated care improves health
In 2009, the Oregon Legislature launched Oregon into a new chapter of health care reform. It approved a program intended to significantly change how health care in Oregon is delivered to patients.
By 2014, more than 400 primary care practices across the state were taking part in the program run by the Oregon Health Authority — called the Patient-Centered Primary Care Home program. The program’s mission is to encourage health care providers to deliver primary care in a more coordinated way, that is more easily accessible to patients, and to use practices that have been shown to improve health. The ultimate goal was to achieve what health reformers call the Triple Aim: better care for patients, improved population health and reduced overall health care costs.
But in 2014, five years after the Legislature approved the program, was it actually working?
That’s what the state of Oregon asked a team from the OHSU-PSU School of Public Health to find out.
The team, working with the Oregon Health Authority, included Sherril Gelmon and Neal Wallace from the School of Public Health, and Billie Sandberg of PSU’s College of Urban and Public Affairs. Gelmon and Sandberg conducted qualitative evaluations of the work of 20 “exemplary” clinics in the program — to better understand what they were doing, what was working well, and what wasn’t. Wallace, meanwhile, evaluated whether the program was reducing overall health care expenditures.
After completing the two-year study, the team found some significant positive results. It found that the exemplary clinics had shifted their clinic processes to allow for better coordination of patient care, shared decision-making between patients and providers, and use of evidence-based practices to improve patient health.
Team members also found substantial savings. They found the program had saved the state $240 million in health care costs over the program’s first three years. They determined that the program had reduced total expenditures per person by 4.2 percent. Finally, they also found a remarkable “return on investment”: every $1 increase in primary care expenditures in the program resulted in $13 in savings down the road — in decreased need for specialty or emergency department care and hospitalizations.
“It turned out we found out what we would hope to find — people were more likely to get good primary care,” says Wallace, a professor and director of the School of Public Health’s M.P.H. in Health Management and Policy program. “And when that was happening, they were less likely to see a specialist, less likely to go to the emergency room, less likely to go to the hospital.”
Gelmon, a professor and director of the School of Public Health’s Ph.D. in Health Systems and Policy program, added that the longer clinics were in the program, “the better they did, because they started to institutionalize some of the new practices into routine operations.”
Previous public health research had explored similar pilot programs across the nation. But those studies often examined programs with only 10 or 20 clinics, Gelmon said. This study was the first to look at an entire system with such a large number of clinics — since the Oregon program was a statewide program that now involves more than 650 of the approximately 1,000 clinics providing primary care to Oregon residents.
The School of Public Health and College of Urban and Public Affairs researchers found that the clinics that were working well for patients were meeting most of the six standards of the program. Those standards range from offering easy access to care, to providing continuity of care for patients and providing care in a coordinated and integrated way.
The successful clinics also had strong leadership, and staff that supported the goals of the program and the changes clinics needed to make to achieve the goals, Gelmon and Wallace say.
The results often meant healthier patients, Wallace said. And those results could come from seemingly simple fixes. For instance, falls can cause major problems for elderly people — problems beyond immediate injuries. A clinic that put a stronger focus on preventing falls with its patients saw those numbers decrease from 39 people falling per month to three people a month, Wallace says.
An important part of the School of Public Health study was to examine whether the state was accurately measuring success in the program. Were the attributes the state was using to measure success the appropriate ones to measure? Did having those attributes equate to better patient health? “We found, in fact, that all of the attributes together made sense,” Wallace said. “Doing better means doing better in all of the attributes — not just one of them.”
The study also found challenges with the program. A primary finding was that, while changes that clinics made improved patient health and saved the healthcare system money, those changes often cost the clinics money and resources. And the return on that investment ended up elsewhere in the health system.
“The clinics feel that they’ve been asked to do a lot and haven’t received a lot of compensation from the state,” Gelmon says.
Another primary question is whether the changes in the system are sustainable for the long run. Wallace and Gelmon say they’re seeing core patient-centered primary care home management practices beginning to be embedded in how the exemplary clinics operate. “The alignment that’s starting to happen … I think it’s going to continue,” she says.
“The really big question is how you get that spread across the whole system,” Wallace says.
Gelmon says the research examining the program was a great example of public health research at its best. It was research into the real-world implementation of a policy in the School of Public Health’s own community.
“It’s relevant and it’s us talking about where we live,” she says. “It’s validation that a policy being implemented is actually making a difference, and it’s real data from real people on the ground, with the research conducted by faculty and graduate students in the School of Public Health.
“I think it’s a great illustration of the potential we have to do relevant research, especially for the school going forward. This is research that not only has great academic merit but also actually makes a difference.”