Medical home focuses on engaging patients

Approach helps maximize visits with physician

A week or 10 days before patients have an appointment with a physician at Primary Care of Southbury in Danbury, CT, a nurse or medical assistant calls them to determine if they've been following through on their treatment plan and have everything in place for the appointment.

"The goal is not to wait until a patient comes to an appointment and has forgotten to get lab work done or record his blood pressure readings. We are being proactive to make sure we have everything needed to make the most out of the visit," says Robert Carr, MD, a physician at Primary Care of Southbury.

The initiative is just part of the Danbury Office of Physician Services' efforts to advance quality health care by creating patient-centered medical homes. The organization is a large multispecialty physician group that works closely with Danbury Hospital.

Primary Care of Southbury and Brookfield Family Medicine are the first two practices in the organization that have been certified by the National Committee for Quality Assurance (NCQA) as patient-centered medical homes.

"The benefit of being a patient-centered medical home is that we can coordinate care for patients across the whole health system. We don't wait for the patients to make an appointment for an episode of care. The goal is to maintain an ongoing relationship with patients and proactively address their chronic health care needs as well as treating any acute complaints they may have," Carr says.

The emphasis in a patient-centered medical home is on strengthening the doctor-patient relationship and creating a long-term relationship between the patient and the treatment team, Carr says.

"It's like the old-fashioned family doctor of decades ago; only now the physician is working with a multidisciplinary team that may include nurses, dieticians, therapist, pharmacists, and others. All of the patient's health care needs are coordinated through the medical home, either on site, or along the continuum of care. In the old model, it was easier for things to fall through the cracks. Now we work with the hospital case managers and visiting nurses to make sure patients get everything they need," Carr says.

Under the old model of care, the physician would give the patient a treatment plan and ask him or her to come back in two or three months for a follow-up visit, Carr says.

"By that time, the patient may have forgotten the plan or not maintained it," he adds.

Under the new system, a nurse contacts patients between visits and makes sure they understand the plan and are following it and that they have the necessary resources to manage their condition.

The contact between visits helps patients become engaged in their care plan rather than thinking it of as something the doctor is doing, Carr points out.

"This is a more proactive and comprehensive approach that continues over time so patients don't feel like they get attention only every three months," he says.

When patients are diagnosed with a chronic disease, they need more attention than the treatment team can give them during an episodic visit, Carr says.

"We do a lot of population management. We know who the patients are who have diabetes, congestive heart failure, or other chronic conditions. We keep in touch with them proactively so we make sure they get the preventive care and patient education they need in addition to acute care. Not everybody needs contact between visits. On the other hand, some patients have so many comorbidities that they may need several contacts," he says.

The model focuses on patient engagement so patients feel like they're an important part of the healing process, Carr says.

"It's designed to be more personalized and to give patients help in being successful. By coordinating all aspects of care throughout the continuum, we help patients navigate our complex health care delivery system so nothing falls through the cracks," he says.

For instance, the hospitalists in the medical group alert the individual practices when their patients are in the hospital.

The electronic system also connects specialists and the primary care physicians, making coordination of care easier, Carr says.

"All offices have online access to the electronic record, the physician notes, history and physicals, and can follow the patient while they are in the hospital. The primary care physician automatically receives a copy of the discharge summary from the discharging physician," he says.

The hospitalists and discharge planners at the hospital have access to the appointment calendars for the primary care physicians and can schedule follow-up appointments before the patient leaves the hospital.

"They can go into the schedule and make a follow-up appointment for a patient without having to talk to the office staff. In the old system, the hospitalist would tell the patient to follow up with the primary care physician, and they might not be able to get in for six weeks," he says.

The primary care offices have allowed double-booking if it's a hospital follow-up or they have appointments available for people coming out of the hospital, he adds.

When patients are discharged from the hospital, a nurse from the doctor's office follows up with them to make sure they have everything they need to recover at home and that they have a follow-up visit with a physician.

"The time most people experience problems that send them back to the hospital is between the time they are discharged from the hospital and the time they see their doctor for a follow-up appointment. That's why we have the nurse contact them in the interim to make sure they understand their discharge instructions, that they have medication and equipment they need, and that they have transportation to the follow-up visit," he says.

Sometimes patients have appointments with their primary care physician and a specialist. In these cases, the nurses help them sort out which visit is for which doctor.

Another benefit of the patient-centered medical home is that everybody in the physician office works at the highest level of their license, Carr says.

"The process of patient care begins at the front desk and continues with the medical assistants and nursing staff, freeing the doctor to focus on the patient's more complicated medical needs. Each profession is focusing on the things they do best and fully utilizing their skills and talents," he says.

For instance, people at the front desk may recognize things a patient may need for the visit. For instance, if the patient is going to need lab work, they make sure that it's done before the doctor sees the patient.

"A lot can happen before the doctor walks into the room. In the old model, the staff mainly focused on getting the patient in the room and ready to see the doctor. This model engages the whole staff to be more involved in patient care," he says.