Medical Homes on the Prairie: A New Structure for Care Delivery
According to the NCQA, the national certifying body for what they term Patient-Centered Medical Homes, a Medical Home is a primary care setting that “facilities partnerships” between patients and providers and one in which “care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.”
Or as Laurie Jensen, Director of Clinic operations at Sanford Luverne Clinic, itself a certified Medical Home for more than a year, explains it, “It is about achieving a team, including the patient, the doctor, the RN health coach, the family, etc., that works together to optimize care.”
“This is not a program, but a philosophy of how we manage care.”
Chad Markham, VP for Clinic and Network Development at UnityPoint St. Luke’s in Sioux City, puts it even more succinctly: “It’s about setting up a network of people to make sure that no one falls through the cracks.” UnityPoint St. Luke’s new Sunnybrook Medical Plaza in Morningside, includes a primary care clinic designed – both physically and logistically – entirely around the Medical Home model of care coordination.
“We visited many other clinics that had be ‘retrofitted’ as Medical Homes and we knew that there were certain structural features that we wanted to bake into our project,” says Markham. “One of them was a larger nurses’ station so that the physician can more easily sit the with nurses and discuss next steps for the patient, instead of just going directly back to his or her office.”
Patients at Sunnybrook will be risk stratified using population analytics and referred to a care coordinator for connection to additional services, as needed. Although any patient is eligible, the system will be most beneficial to patients with chronic and multiple medical issues. Markham says such a design allows physicians to see as many as 5 to 10 percent more patients “and still go home by 5”.
What’s in it for Doctors?
It is not difficult to see how a model designed to systematically provide more comprehensive care to the sickest patients will benefit patients. But what does it mean for doctors across the Northern Plains, many of whom are just beginning to hear about or experience the system for themselves?
“Almost every physician initially reacts by saying ‘I am already doing this’,” says Markham. “It is almost as if you are saying that they haven’t been doing something right. The problem is that it hasn’t been systematic. It may have been great care, but it hasn’t been proactive.”
And all indications are that it hasn’t been working for doctors either. Sixty-five percent of physicians are so frustrated with the current state of healthcare, that they would retire tomorrow if given the chance. With physician burnout at an all-time high, local healthcare organizations are hoping that a system that removes some of the time pressure will help. Under the Medical Home model, the most costly and time-consuming patients are funneled into a system to connect them with needed support services without clogging up the works or throwing off the schedule.
“I would see one of these patients with multiple medical problems show up on my schedule and think, ‘Oh my gosh…. This patient is scheduled for 15 minutes and they are going to take up an hour of my time!’,” says Tad Jacobs, MD, Chief Medical Officer for Avera Health. “When you are chasing your schedule, it is hard to give the detail of care that you want to give. Often, after you see one of these complex patients – say, a diabetic –you would wonder, ‘Did they really get what I was telling them?’”
Avera’s answer is the Avera Coordinated Care Program being implemented in 6 regional hubs, including Mcgreevy Clinics in Sioux Falls, where the first patient was enrolled this spring. As with most Medical Home-like approaches, the system will focus first on the sickest patients, a task made more feasible – if not exactly easy – by electronic health records and registries.
“When we visited some other Medical Homes, we found that the health coach, or care coordinator, was often very overwhelmed with collecting this kind of data,” says Dave Flicek, Senior VP for Avera Medical Group. “So, in our model, we have included a documentation specialist whose job it is to go through the medical record and help support the nurse in coordinating care.”
“The biggest challenge has been getting doctors to understand how this is different from what they’re already doing,” says Terri Carlson, VP of Sanford Clinics, where the Sanford Medical Home model has been used in some form for 6 years. In the last 2 years, RN Health Coaches have been made available to all Sanford Clinics.
“What has been fun is when we have doctors who were not initially sending their patients to the health coach, come back and say ‘Wow! What have you done? I have been trying to get this patient to do this or that for years and they finally have!’ It increases physician satisfaction to see their patients doing well.”
Beyond boosting patient care and physician satisfaction, the other major aim of the Medical Home idea is cost savings. As more patients use Urgent Cares and Emergency Rooms as their source for primary care, costs are driven up, the system is bogged down, and underlying medical issues remain unaddressed. Systematic care coordination of care, in contrast, saves money in both the short and long term.1
“As we look at the future and at accountable care organizations, population health is becoming increasingly important,” says Amy Slevin, RN, Director of Clinical Program Development at Mercy Medical Center. Mercy currently has five primary care clinics in the process of Medical Home development. “We know that a healthy population uses less of the more costly healthcare things. So you want to keep your healthy patients as healthy as you can, and your chronically ill patients in the management category so that they don’t progress into the more expensive category.”
Although Slevin admits that health coaches and the extra time they spend with complex patients is not without cost – and it is a cost that, for now, is not directly reimbursable – she believes it is a cost that will be recouped over time.
“If we are managing these patients correctly according to the Medical Home concept, there is likely to be an increase in revenue in the form of more regular office visits, additional screening tests, certain lab work, etc.,” says Slevin. “But by making sure they get these relatively low-cost services when they need them, we hope to keep them out of the hospital and the emergency room, which are much more expensive.”
By focusing on a technique called motivational interviewing, health coaches or care coordinators, who are usually RN’s, enlist the patient’s participation in health modifications such as lowering blood pressure, losing weight, addressing psychosocial issues or managing diabetes . Patients may be referred to dieticians, counselors or social workers, as needed.
Although the approach is currently focused on the sickest patients, most agree that the greatest benefits will be seen when the Medical Home idea is extended to all patients. Medicaid is already forcing the issue in many states with the establishment of the Health Home initiative for high-utilization individuals. While it remains to be seen how many patients can feasibly receive care coordination under the current model, those involved in the experiment say the system is clearly here to stay.
“This is our new way of doing business,” says Dr. Jacobs.