therapeutic intervention around changing the sleep parameters for the c-pap machine, how do you incorporate that into your clinical workload. that's a simple example. if you have poly chronic conditions that gets much more complex. some of the other once was could they potentially improve the diagnostic ability. they thought if we can improve the safety or patient adherence or our ability to validate our diagnosis through the sensors and other data that can be collected on smartphones, there may be value here. we want to keep this in mind too as we looked at these digital health hybrids that are proposed to us. so one more click. and so at a very high level, we talked a little bit about navigation. we looked at the continuum of what the possibilities are. we also looked at advocacy and a couple of digital health.

we talked about what the clinician academies are spoke what wdoing.i'll hand things ba. thank you. >> thank you. >> great. >> so in terms of next steps, as you know, it's part of the strategic road map with health navigation and there's obviously an r.f.i. going on right now to understand what is out there in the marketplace and what the scope of services can look like so we're assess tag and in terms of the looking at are those services that we could partner with the current health plans to explore and expand and how they would be integrated if it happens to be a point solution approach. so that is all in the process. >> one of the things that has struck me is how do we begin to at least prioritize where we want to start. it's sort of like, you know, there's all this stuff. that is going to be a key in my

understanding about the value of this at the end of the day. during the navigation session, we had all of the vendors come through and they all looked bells and whistles and you want to touch them and put them on your tree at the holiday season or something. again, trying to figure out where to start. i mean, for us to start from a program standpoint, not where to start in the navigation process is going to be a trick. >> we have narrowed the focus for the r.f.i. so we will only look at certain categories. the navigation coordination, the skeletal -- help me out here, guys. >> expert opinion. >> expert opinion. that's where we're starting. >> ok. >> some that are familiar and some new to us. yeah, we share your concern and part of what we're learning and i think clearly from the

presentation weren't the only one that is trying to design or understand how to go about evaluating these tools. that's why it's an r.f.i. so we can learn about it and i know that the plans are all doing some more work so we want to be sure that we are talking to each other as we move along and see where this synergy is and consensus around some of these products. >> one of the things i was hoping to learn about in new orleans because the fact is that we have a potent data base now. they've been working on it for quite a while as a health system. we can use that to drive some of the prioritization, muscle skeletal came up in part through that data base and in addition to the fact i would say we're way ahead. we own that data. that's our data. that is a step ahead where lots

of health plan providers out there find themselves not knowing what they're creating and how much. just protect my image as being the dr. cynic, it allows for in ovation and to be open to looking at random eyes trials to help drive this. if there is issues that overlap we should consider it because of the potency because of the number of members we have and the data base. >> any other comments? questions? >> thank you, very much. any public comment on this? >> heb bert wiener. this is very complex. i don't pretend to understand it. i'm sure the average individual

who is beneficiary of the health services system will have a difficult time. basically, i think despite the comprehensiveness and effectiveness of any system you are going to need an advocate to guide them through this mind field. you need an advocate and you are probably going to have to put out a pamphlet saying you are right at hss. and it should detail every situation. like for instance, if you have a medical emergency and none of you guys are available on the weekend, that is going to be very important. it's what you can do. it's not simply a question of dialing 9-1-1. so i think that it's a good idea. what we want to do is we want to make access to the system more easy.

and i can remember 30 years ago if i had a problem with hss i would go to the supervisor represented on this board and talk to their secretary and they would wrestle with you guys for about three months and finally, we want to have really efficiencies. i don't pretend to comprehend anything. i i think you understand it better than i do but i have really been barraged. i can understand the mission but i think it's basically for the recipient of these services. >> thank you. >> any other public comment? >> seeing none.

item number 5. item 5 discussion item. primary care medical homes. presentation by mairianna kong, md. >> welcome back. we've been communicate biggy male so this is a first in-person. and dr. kong is the physician practice transformation specialist at the center for excellence in primary case at the ecsp and a faculty member in the department of family and community medicine. she leads the clinic first initiatives at the center for excellence in primary care which aims with best practice and primary care teaching clinic transformation. dr. kong is a primary care providers at the san francisco department public of health at the family health center which i understand he was working at prior to coming here today. and she completed her residency and family and community medicine at ucsf and obtained

her medical degree. her interest include primary care transformation and innovation and under served communities, immigrant and refugee health and social determinant of health. very much appreciate you coming here today to school us on primary care medical homes. thank you. >> thank you very much. good afternoon. so, as mentioned i'm mairianna kong. i work at the ucsf primary care. our mission on the next slide, has been to identify, describe, evaluate and disseminate innovations across the country with the goal of achieving the quadruple aim. our work is in researching these initiatives and also spreading them and training others to implement these innovations. so today i'll be talking about, first starting off with some context for the need for primary care transformation and then giving a primer about what

patients under pcmh what it means and what it looks like in the country right now. what it looks like to implement that in a population that would be similar to the hss members. so in general, broad context, the healthcare in the united states we should be doing much better than we are. so compared to many studies, compared to other countries, especially industrialized nations the outcomes of our population are extremely poor. especially in comparison to how much we spend on healthcare so this is a figure from the world health organization comparing the united states outcomes in infant mortality and life expectant see compared to others and we do fairly poorly on most of those metrics. why is that when we secon spendo much on healthcare. along the line of developing a lot of highly tech logically advances medical interventioned

and cutting edge specialty care we've forgotten the importance of having a personal doctor. this is from former president barack obama where he said, it used to be that most us of had a family doctor. you would consult with the family doctor. they nuu-chah-nult knew nur his. how do we get more primary care physicians and give them power so they are the hub where the patient-centered medical home exists. getting to the importance of primary care as a foundation for a quality healthcare. when we talk about primary care of, one good way to define it is the four c functional definition identified by dr. bar ra starfield who is a pediatrician and international experts on primary care. the hall marks of primary care, being it's the first contact. the first place where people go when they are looking for healthcare and related needs. comprehensiveness, not only focusing on one organ system or body part but taking care of the

whole person. continuity, having a team on providers that know you and know your family and know you overtime as opposed to having to reexplain all of your history to someone different every time you would have contact with care. and coordination and so as we've heard, healthcare is complicated and having a source of coordination to make sure the efforts are aligned to duplicating care and perhaps doing harm more than good research concludes the nations over reliance on specialty care at the expense of primary care leads to a health system that is less efficient. research shows preventative care, care for the chronically ill and continuity of care are all hall marks of primary care medicine can achieve better cost outcomes and cost savings.

as an example of some of the evidence for this on the next slide, this is a study from health affairs in 2004 that looked at medicine medicare claa and compared quality metrics with the concentration of primary care physicians and you have higher quality metrics and they looked at 24 different metrics looking at healthcare quality. when you look at cost, the higher of the concentration in a area of primary care providers the lower cost and spending on healthcare and part of the reason is the people that have a primary care provider are more likely to receive preventative services, more likely to obtain medical treatment before they develop into serious problems and they have fewer preventable emergency department and hospital visits.

in the united states, one-third of adults don't have access to a primary care providers. three out of four can't get off office care and we have a primary care provider shortage so there are new physicians entering the care field for several reasons. it's been known for a while the demand for primary care is easily outstripping the growing or the lack of growth in supply of primary care providers. on the next slide, when we look at the work of primary care how is it do able and the average patient panel in the united states is about 2300 and so two studies looked at rounding up to 2500. what that would like look in getting the required preventative care they recommend

preventative care so recommended vaccinations and recommended cancer screenings and the things that guideline and physician groups have agreed that every patient needs to have and so patients with diabetes, getting the care those conditions require, adds another 10.6 hours per day for a loan single provider to do that for the panel of patients which leaves a lovely six hours to deal with all the acute problems. so it's not a sustainable model. to think about doing the work that we know that modern primary care involved, in the old model of the single provider without a team and without a patient center medical home taking all of that on themselves. >> i have a question. how do you define afternoon avee patient? >> panel size of 2500.

>> i know that kaiser and other plans are based on diagnosis, et cetera. so that someone who has more chronically ill patients with more diagnosis would fall into that. their panel may have fewer members but they're still giving credit for a full panel. this is a little misleading to me in terms of 2500 healthy patients aged 30 or 2500 patients across the spectrum including infants and i just don't know what this means. >> it's a great question. in those two different studies, those authors, i believe, took a example of patients across the board. not only limited to healthy patients but tried to sort of average all the recommended care that an average american patient with diabetes or hypertension and using the frequency of the

type of patient into their calculations. >> basically a panel that might occur in every town u.s.a. >> exactly. >> not necessarily in larger cities or whatever. they provide a wider range of services, including gynecological services and obstetrical services. >> i don't know if that was included. >> i know what you are driving at but you know, it gives the impression that no good doctor could be providing care at this time. no good doctor with work 18 hours a day. and so it is a little frightening. >> yes. i would agree with that as a primary care physician but it is frightening. many physicians would agree. their reason for more type of alternative models like concierge-type services have

come up because doing all the care that is needed for a typical-size panel for the united states is impossible to deliver the right quality of care. patients have poor access because they have the demand for prime primary care. you are getting inconsistent quality because as we're seeing, that it is very difficult to do the amount of work that is needed just to provide standardized quality of care recommended and according to guidelines, and there is a lack of time to build relationships with patients because they try to squeeze that work into one day we're looking at 15-minute appointments so 20 and plus patients a day for bun provider to see. clinicians are getting burned out. when they move into other fields or retire, that earlier because of the difficulty of managing the work, you are exacerbating the primary care shortage as well.

it will fit the 21st century healthcare needs. and just thinking about how much more we know now about preventative and chronic care compared to 50 years ago there's much more in terms of the standards that we want for patients and our population than there was 50 years ago. so, this was out -- i was going to talk about how it fits into this and so the patient center medical home to give an introduction to where that term comes from and what if means, initially it was coined in 19 #7 to refer to have one place for a record for a child or pediatric patient with complex medical needs. from that it grew into the idea that in addition to having one

place for records, we should be thinking about one place for care and one place for coordination. and so, by the 2000s in 2007, four large physician groups including the american academy of pediatrics and the american academy of family physicians came together to develop what is called the joint principles of the patient-centered medical home. what does describe was what should ideal primary care look like about the needs of the population and what are those core qualities that we need to have in good primary care. so those are listed here and this is how it is described by the agency for healthcare and research quality and many organizations have slightly different language to talk about the concept of the patient centered medical home. they have in common the core concepts so first, again, comprehensiveness and thinking about how we frame care so it delivers to the needs of the patient as opposed to what is most established and easiest for the health-care system to do because it's what we've been

doing. a very coordinated care. accessible care. people can actually reach the care when they need it and the type of care that they need. it has good safety and it's high-quality. so, how do you know if a place is a patient center medical home and so many organizations are crediting organization and states and other groups have defined what the checklist is criteria that need to be met to be considered a patient-centered medical hope. the most common is national committee of quality assurance, this is common when people about being certified patient centered medical home. on the next slide, this is an example of the checklist that the nsqa has developed to identify whether or not a clinic is a pcmh. you will see those same themes come across here. good access, comprehensiveness and they have assigned scores and have a very defined way of

collecting information from different clinics to decide whether or not they qualify as being able to hit these bench benchmark. the ball has rolled on the pcmh movement and 11 sites were recognized as of 2015. they have different levels as far as how they met the criteria. they provide incentives programs to turn into patient centered medical homes so that's part of the growing movement. so right now the landscape of the patient centered medical home is that over 90 commercial and non-profit health plans are leading patient-centered medical home initiatives. the largest u.s. employers are offering advance primary care which is another way to describe models like the pcmh to their employees. there are many public sector

advantages to pcmh care so medicare, u.s. military and the veterans affairs are providing pcmh models and developing those. private practices, hospital practices and independent practice associations are doing this as well so there's no one sector where the pcmh movement has limited itself to its been across all different types of populations. and so one thing i really think is important to outline here is that we're talking about accreditation and meeting criteria and being certified as a patient-centered medical home but being a pcmh on paper is not the same as being a functioning pcmh in rea we've talked to practices that have put in a lot of work because it is a lot of work to get the certification process going for the ncqa certification. they have put in the work to do it. they have gotten to level 3 which is the highest certification with ncqa but they said we didn't feel like we were

still a medical home that was providing that level of care to our patients so we knew we had to keep going and transforming and conversely there are very high functioning primary care practicing out there that don't have the resources or haven't decided not to place the resources in pursuing accreditation but are high functioning on the less so there's a distinction between accreditation and in reality. and so how do you know what pcmh is in reality. i will talk about the 10 building blocks of high functioning primary care which is at the center to get at what are the qualities of good primary care, what does good primary care look like if i'm thinking about my grandmother or my loved ones what do i want her care to look like? how we develop this model is we did a series of site visits to 23 high performing primary care clinics around the country. they were by reputation and by

quality metrics and we're doing a really great job and doing providing that ideal form of primary care to their patients. and this again spanned different pair mixes, settings, different patient populations and we spent two or three days at each one shadowing in the clinic and talking and interviewing to people in the clinic and talking to patients when possible to nail down what was going on and identify what are the best practices that these high functioning places have in common. and so from that we developed this model which is the 10 building blocks of high performing primary care. you will see on here there are several components that are the same as what we talked about with pcmh because it encompasses those quality and it adds other things that we saw in these high performing practices and structure it in a way where there's an order to the blocks. so the foundational blocks, 1-4 on the bottom are really required to be able to build on and achieve those higher level

blocks. i'll spend time going through a few of these. one, that is particularly important but many clinics are struggling with is 'em panelment, who are the patients that belong to a clinic. who in the providers that work there, who are their patients. many whe -- the patient or clinc may not know the primary care. this is population management where how can you check on what percent of your patients are up-to-date with their colorectal cancer screening if you don't have a firm definition or way to identify who your patients are. this is a foundational block. another important block is that of team-based care.

so there's a lot of talk about how you work as a team in healthcare. so particularly in primary care the thought is how can you redesign your team to go from that old model of the loan physician in the town carrying haze black bag to a full team that is there to really meet the needs of the population based on what those patients need. for example, we have a lot of emphasis on the role of the medical assistant. traditionally they take vital signs, puts the patient in the room and leaves and the doctor does the rest of it. we're seeing in high functioning clinics they've really turned that on its head and engage the medical assistant as a core part of the team for the patient. for example, medical assist ants are able to use standing protocols to identify when patients are due for a vaccination, when they're due for pap smear and be able to help the outreach for those patients. they're able to follow-up with patients and coordination of care and find out what happened with a certain referral and

really engaging that staff into the care team has been a huge benefit to many clinics. so one particular one at university of colorado, as well as bell and health in wisconsin, they've adapted a two medical assistant per provider model with the medical assist ants are in the room during the visit. they have a higher level of engage many. the medical assistant can follow-up with the patient after the physician leaves and can make sure that the plan was understood and all the orders are placed and that all the core nation that needs to happen is happening. so that is one example. and then of course there's the extended team as well of behavior health, social work, and increasingly import ant when you think about complex needs. patients with multiple organ

delivering care than one individual provider can in a 15-20 minute visit. and so block six is population. it's panel management which we use to refer to how you make sure your population of patients is receiving the recommended care that they're supposed to get. it used to be that if a patient comes in and they're asking i'm here for a checkup and to get my recommended healthcare maintenance, then that is the opportunity for primary care to provide those services, however, we know that most people, either can't or even those that can may not come to the doctor and so does that mean they shouldn't be up-to-date on their vaccinations. it doesn't. the idea of population management is regardless of whether a patient is coming in or not and asking for these things or not, how are we making sure they're all getting these things. high functioning clinics are building in time for staff members like the medical assistance or health coaches to

be able to reach out to the population of patients that's not coming in and you use your registry of patients to figure out who is overdue for certain things and you proactively offer those things in a way that is most convenient for the patient as opposed to baiting for someone to come through the door and ask for it. this we heard a lot about already and i think anyone who has had any interaction with the health-care system knows everything still works in sigh lows for the most part and so the hospital is in one area, raidology is in another area and pharmacies are functioning separately and every system has a different electronic medical system, healthcare record system, every system has a different flow of doing things and there's different ways of communicating and most of the time, to understand what is going on to be able to proactively pursue with all these different sectors what their follow-up is supposed to be and it's difficult. especially considering that the patient is typically the one who is not feeling well.

and so that, is extremely difficult and high functioning primary care practices are really shifting this responsibility onto the primary care team and to have one designated person to be able to follow-up on these things so that you know which patients had been hospitalized or about to get discharged from the hospital and will need a follow-up appointment as opposed to expecting this patient who has just gotten out of the hospital mayor may not be in a well state at home to be able to make sure they have a follow-up appointment and come in for that. lastly, this slide is looking at what we call the template of the future. that's the building block 10. what we're referring to is thinking outside the box of traditional care of the provider visit. in a fee for service environment, they are reimbursed when providers see patients. that's how everything funnels down to in the current system for the most part. we just heard that a lot of this work, for example, population

management, and care coordination, those don't necessarily end and shouldn't take place by having the patient come into the clinic and be the one to prompt these things to happen. how do we redesign to look for it and typical and in 20 minutes you have a patient scheduled and that's it and there's no designated time to talk to hospitals talk to specialists and it we're thinking about how you build in time for electronic visits and how do you incorporate care management time or longer appointments for complicated patients to be able to meet with an inter disciplinary team to fully assess what their needs are. there are a lot of possibilities. they do require a different form of payment because otherwise clinics can't sustain that type of work. how do you invest in this time

of transformed primary care and what are examples of that? looking at early evidence, this is a difficult area to study in terms of the effect of patient centered medical home on cost and utilization. however, some preliminary evidence this is a report from the patient centered primary care collaborative. we're looking at a review of evidence that they did looking at multiple studies that included some type of cost metric or utilization metric. and they did see a trend towards most of these studies finding some improvement after a clinic had chained into a patient-centered medical home model, however, this is after the fact. and so, up front in order to get to that point, it requires investment of resources. and so, we're really thinking about how do you support this type of transformation which requires going beyond the traditional fee for service model. so in some places, this means a blended model that has still restained some quality of fee

for service but has a comb phone ant to a care coordination fee is an example of what that might look like. how do you have more comprehensive population based payment models leaning towards full captation. some places are getting direct funding for team resources so there may be certain funding dedicated towards improving access to bee hair yearal health so it's funded directionally. there's a lot of pay per for formance that are basically providing extra funding if clinics are able to meet certain metrics and lastly how do you support they running of the clinic and seeing the patients there so we're transformed to a higher functioning model of care. so some examples we have of those different ways that the pcmh model is being supported

and implemented, the ucsf health, they have undergone a primary transformation that is based on the 10 building blocks models. with an explanation of a quality of good primary care because of the way it is organized and laid out it provides a road map for transformation. and so, since doing this, they've seen impressive gains in quality access patient experience. quality metrics such as mammogram and pap smear screenings but in metrics across the board as well. and part of the way that they were able to do this is actually using the infrastructure from the medical waiver public incentive program which again provided funding for meeting certain metrics and dedicating resources to doing things differently. it was critical for motivating and resourcing the primary care improvement at ucsf health and they aligned the way this program looks with the growth of

ucsf health aco programs with blue shield to develop a shared saving program that was again, a way to support the transformation and dedication of resources to this new model of care. other ways around the country is one example is the center for medicated medicare service and they have launched a comprehensive primary care plus initiative which nation wide has been a provided alternative payment model for clinics that were invested and into developing the patient centered medical home to be able to support this and this has been on going for years but it's continuing and an ongoing project. another is the practice transformation initiative which is the california quality collaborative has been training practice facilitation coaches using the 10 building blocks of primary care model and so these coaches are then going out to

clinics and being the catalyst to really launch these changes and again providing that support and basically that effort to make these changes because again, the people on the ground are really trying to run the clinic and keep it standing for the patients that are continuing to come and so there's very few scenarios where a clinic can shut down for a month to redesign their operations and so the practice coach idea is that these coaches support each other with quarterly meetings and going out to thousands of clinics to be able to spread the model and use a 10 building blocks model to help clinics transform and redesign what their care looks like? this is an example of the provider organizations participating in this initiative which we see span a variety of different types of setting and this has had a lot of through

their benefit redesign is their plans don't have detectable to go into primary care and this is a huge barrier to access at all for most patients to access service that's we are agreeing that every patient should have they're requiring they have a primary care physician and i am panelled to a designated provider. their payment reform and to move to the cpc plus model which offers different options that are related to pay for performance and they're encouraging their health plans to really ensure a larger share ofen rollys to receive care from a pcmh designed practice so some

take home points is it's the foundation for better healthcare and achieving the aim and the patient center medical home is a model of care to be able to improve on all of these areas and again, that pcmh on paper is not the same thing necessarily as pcmh in reality and the resources are required to be able to support the transformation to this higher level of primary care. we have further information on our website and we're always happy to share. >> one comment is, thomas bodden hymner was a colleague of mine in 1982. it's nice to see it looks healthier and happier not providing primary care seven days a week basically and so he seems to be a an example of what

you are talking about. you mention mention kaiser. half my professional career was primary care and the other half was doing infectious disease at kaiser and many issues are implemented at kaiser and some have been abandon. your work flow day i have to say that model has been tried and no way that one can do that and some patients take longer so you can't huddle and you think you can and the pay for performance.

>> it's a huge area that we're seeing more and more. they invest resources in and one thing that is extremely important in team base care is actually having a team that is intact and table and meaning they are working together in time. typically we're seeing that providers are paired up with specific medical assistance and varying in number and that they're working with the same ones overtime so what happens is that providers panel of patients becomes that medical assistant or couple of medical assistance becomes their panel of patients. when we're seeing that the support medical assistance to be able to take on more roles by

doing more training and providing protocols on check for healthcare maintenance items for these patients is this patients has diabetes on their record we know we're going to be doing a foot exam on collecting a urine and doing an eye exam and so when you have those protocols in place, you see on a day to day basis that medical assistance are actually feeling a lot more opioid of patients a -- ownershy feel these are my patients because we're on the same team and providing care to these patients as a team. you see that happening from the patient perspective as well saying oh i need to look for drd to look for jackie, she's my medical assistant and i know her and i know she'll get me the care that i need and help me figure out what i'm going to get into this particular specialist or something like that. and so, it's definitely a complex process to get to

because of the traditional barriers and many folks run into issues with perceptions about scope of practice and what is ok and not ok to have different team members do. what we're seeing in these high functioning practices is that when they invest in providings and that there is actually a lot more the team members can do and do better than providers. one practice we visited, they found that trying to meet 100% of this metric when they told providers when you see the patient that needs this remember to order it. it would happen 70% of the time because so many other things get in the way during that visit. when they actually created a work flow and had staff take ownership of making sure everyone that was due was getting colorectal screening their numbers would shoot up to 100% because their staff were better when they have an algorithm to follow it and make

sure they hit it 100% of the day. >> can i make one comment. i certainly he worked himself to death to keep up with me and the nurse practitioner he was assigned to. if he was out, then it became kind of a pool. the model looks good. it's really a more than simply one-on-one relationship because that is impossible. you will never achieve that. with vacations and illness and all kinds of things that can happen in a day to day functioning of a practice, and so i guess i'm still interested in your comment about how the group of all the medical assistance can be brought into the process to support all of

the providers and in fact take ownership to these problems for the whole panel of patients because a practice may have 10,000 patients if there are four providers at 2500 each then they have 25 and other than that one-on-one and i get to like my physician or my medical assistant a lot, what motivates people? >> so, this could be a whole other day-long talk about how do you make the team base care work and keep it sustainable but i'll try to keep it succinct. a couple points you are making are true. medical assistants and physicians are also humans that sometimes are sick and sometimes can't come to work so there is a really important standardizing those work flows in the clinic and cross training staff so that you have a system where someone

can float into someone else's position and really cover for them and. >> where they're using two medical assistants per clinician in every clinic half-day. each of those medical assistance is working with six patients as

oppose today 12 and they feel comfortable to do what they're being asked to do and then some. and the kicker there is the access has improved. asking a provider to see an additional one to two patients if you have the support of two medical assistance is do able. i guess hire another provider but you are just expecting to have a larger panel of patients. >> suppose they wanted to go to something like this in this area, where would you direct them? >> great question. so, it is difficult to know without, i guess, knowing where to look for this type of

information. many people might start with looking for a practice that is ncqa a countdown for example but they're also practices that do well but have not pursued accreditation. an example, we've had positive experiences seeing the transformation process play out in the uc health clinics. i work in the department of public-health and we're able to redesign these work loads to achieve different things despite being a different patient population. so it's different to know, although definitely wor of mouth can be helpful which is why one of the top patient experience metrics is asking patients would you recommend this to another family member to go to for care? because patients can feel it when they're in the high functioning practice that when they call they can get the care that they need and they get their needs taken care of and it's not expected that the patient is taking on all the

coordination responsibilities on their own. >> do we have a mechanism to -- when a person might call into customer service and say they're looking for this type of model in their health plan? where are we? >> not currently. >> not currently, ok. that's what i thought. the education here today for all of us. >> ok. >> so in san francisco, how many of these would there be? >> when i looked at the ncqa map, if we use that as a starting place to look at practices, the uc health ones in san francisco are certified level 3 as well as the northeast medical services and so those as well and he came up on the map which doesn't mean they're the only ones that work well but they work well and have you know

persuade the accreditation for it. >> is kaiser on the list? >> it's not on the list. i'm not sure what the conversation has been kaiser determine whether or not to pursue accreditation and they definitely do extremely well obviously on many of those building blocks that we talked about in terms of how they have approached some of the team-based care models, for example, that does look different as you have mentioned, they found some things didn't work for their particular model and so that's also to say that there's no one prescriptive patient centered medical home so every geographical region, every patient population has slightly different needs and it's going to look a little bit different and they will try different things so not every pcmh will have this same, for example, exact staffing ratio or exact work flow for this or that but, what the 10 building blocks points so is that underlying

those logistic differences that there's a core commonality of those themes of providing some expanded team-based area that patients are in panels and they're accurate. the clinic is using data to learn about what they need to do next and do continuous quality improvement and there is a high level of access and comprehensiveness and we have a lot more about how you evaluate each of those building blocks actually. so, we've developed a 10 belong blocks primary assessment tool which is designed for clinics to do self assessments. where they are on each of those 10 building blocks, that's been closely correlated with the similar tool by the safety net medical home initiative as well. >> i'm sorry to dominate this but, you know, one of the things that i was a sub specialist. i also did primary care. one of the things that sort of was missing from your building

blocks but embedded in access to carb was access to sub specialty care. i can tell you as a primary care provider and infectious disease provider at sky ser, if patient at a skin problem i could get a dermatologist the time the patient was there. as an infectious disease consultant, if a doctor called me and said we've got so and so here would you see him, i could actually go to the doctor's exam room and see the patient with the doctor or the patient come to me. that is now much more universal at kaiser with all the sub specialists and orthopedic surgeon on the phone and say so and so has this and we would arrange the care with the patient in the room at the appropriate site. i'm sort of missing from your building blocks, unless it's embedded there. it's an important component as we look at services we provide. >> it's definitely very

important. care coordinations and there's two size and the more you can provide in that primary care the less coordination you have to do because it's all under one roof. for places where it's not possible or services where it's not possible, how do you coordinate to make sure it's linked up with the primary care office to cyst patients in the best way without the patient having to go between two and repeat everything that the other one is saying. and so, yes, that is a crucial component of it. how much of it can you bring in under the same roof as primary care and when you can't, what are your structures and work plows to make sure that care doesn't fall through the cracks by having the patient go elsewhere. >> thank you for your presentation. i think this is really an awakening for us. having worked for public-health,

although not at the medical field. i think a lot of the public-health the difference from clinics are not really certified but they're trying to achieve this medical. so in terms of the members, it's hard because of the absence of a lot of primary cares and if you are a if you patient, you are only given a limited number of choices with care because most of them are specialists. quite a few of them are just one person physicians. the care coordination you don't get it unless you could get the doctor. there's a group of doctors in one clinic and then there might be some care coordination but

still your care is your provided doctor and there's no care coordination in terms of our emphasis members. kaiser might be different because there might be some care coordination but for a lot of our members, it's just your doctor. with that doctor being sick, it's hard to get to then you are on your own. >> that's a great example of what many clinics are facing right now in terms of the the past, you may have not had access to specialty care because either at the time that sub specialty didn't exist or the need wasn't recognized. how do you get that information back from the places because before in the past, you could be that you know your referral to a hem atologist might be a slip of paper and it gets faxed

somewhere and five years later that paper is found in the bottom of a drawer. what happens there no one really knows. for many places in the country that that's still the way things work unfortunately. and so it really points to again how do we create bigger systems to coordinate well. a department of public-health having an electronic referral system where that tracks and helps with communication between primary care providers and specialty care is a huge tool that is being used for a long time now. thinking ahead to as we're thinking about technological advances and more advanced electronic health records, how do we promote that type of coordination as opposed to reinforcing the sigh lows wher . >> this is encouraging for me because my daughter is applying for family medicine residency next year.

it's encouraging and i can relate this to her. >> is there anything else? any public comment? thank you, very much. >> herbert wiener. this is been a comprehensive presentation. it will be for referrals and all sorts of sicknesses. i think of what happened in louisiana in new orleans in 2004. where there were all sorts of disease that's occurred. the primary physician would be very important making the proper referral and this system could be a basis for that. i think it really underlines the

importance not only for regular patient care, but foresee for se efficiency in patient care. when i had a liver problem my primary physician referred me to the best liver specialist in the country. broadly, this is going to be extremely important. these are my comments. >> thank you. >> would you identify who you are for the record. >> oh, i'm herbert wiener, i'm a city retiree. the only thing i have after my name is msw phd. >> if i could make a follow-up comment, having sat as a member of the medical society on the emergency response team for the city and county of san francisco as a member for a short time, the city has a very robust plan

that involves all elements of healthcare delivery. you can imagine, that any one or many sights of normal care delivery are in fact like in new orleans destroyed in a disaster and the city really has a -- i'll put in a plug for the city's natural disaster response program. it's invisible as citizens but it's there. i am quite impressed. >> i'm sure the primary physician model could strengthen that. that's al all i'm saying. >> any other public comment? we need a motion to adjourn. >> before we do that, i like to thank abby and the team for putting together this agenda today.

as we go forward, if we're going to address these issues, they're going to be critical and i will send an e-mail to abby to highlight those and to the board secretary. particularly as we're trying to -- if we're going to assess this myriad of digital navigation tools and so fourth this one page, sharon particularly likes one page models. there are a couple of one-page models in some of these presentations that we need to have as a continuing reference point. if we come back to making a decision on that particular item. same thing with the 10 building blocks that were presented. if we are going to consider the concept or elements of medical-based tones. there are two or three pages out of these presentations that should service reference points for us if we ex back to the topic. that's all i'm saying. thank you for the afternoon, all

of you. >> i'll second that. thank you to the director, abby and the staff for giving us a good educational forum presentation and also thank you to all the presenters. it's been very good topics. and a lot for us to learn. thank you. >> motion to adjourn. >> i move that we adjourn. >> second. >> all right. >> everyone in favor. >> all in favor. >> aye. >> in favor, please stand.