Health plan, medical practice team up on home pilot

Nurses coordinate care through the continuum

CIGNA and Dartmouth-Hitchcock have joined forces to improve care coordination and quality of care for patients through a "patient-centered medical home" pilot project.

The pilot, which was launched on June 1, is one of the first collaborations between primary care providers and a private-sector health company.

The patient-centered medical home model of care aims to provide patients with primary care through coordination of care, timely access to physician visits, enhanced communication between patients and providers, and education to help patients navigate the health care system.

A key component of the model is personal contact by nurse care coordinators located in the physician offices, who are trained on health coaching, motivational interviewing, and assessing patients' readiness to change and provide care coordination, follow-up telephone calls, and health coaching to patients with chronic diseases and complex needs, says Barbara Walters, DO, senior medical director for Dartmouth-Hitchcock in Lebanon, NH.

Participants in the pilot program are patients who receive care from Dartmouth-Hitchcock primary care physicians practicing in family medicine, internal medicine, and pediatrics who are insured by CIGNA. About 19,000 CIGNA members receive care from a Dartmouth-Hitchcock primary care physician.

"The patient-centered medical home is an effort to revitalize the concept of primary care physicians and their affiliated clinical teams working collaboratively with patients to coordinate and assure appropriate health care for all the patient's needs," says Dick Salmon, MD, national medical director for CIGNA.

Before beginning the program, CIGNA increased its compensation to the physicians so they could hire nurse care coordinators on staff.

"The financial pressures of the last 10 years resulted in many primary care physicians hiring medical assistants instead of nurses and hiring fewer of those. What this initiative is trying to do is reverse that trend and make it affordable for physicians to add nurses back to the office staff to help coordinate care of complex patients," Salmon says.

In addition, CIGNA created a reward system for the physician practices. Dartmouth-Hitchcock qualifies for additional compensation if it meets quality goals, based on HEDIS measures, and goals for total medical cost.

CIGNA and Dartmouth-Hitchcock have worked together to promote better communications between case managers in both organizations.

"Traditionally, our case managers haven't had a lot of [interaction] with treating physician practices. We have built lines of communications so the case managers who service the area in which Dartmouth-Hitchcock is located know who to call if they are trying to help a patient who is being treated by a Dartmouth physician," Salmon says.

The collaboration will also help the physician office case managers, because they know who to contact if they need to coordinate patient benefits or want to get the patient into a disease management program, he adds.

"We have set up communication interfaces with Dartmouth-Hitchcock and our case management, disease management, and behavioral health programs. We want to create real collaboration between the clinical resources of the health plan and the physician practices," he says.

The patient-centered medical home program aims to provide coordinated care for patients and to develop a method to make doing the right thing clinically also a reasonable thing from a business point of view, Salmon says.

Where fee for service falls short

The current fee-for-service system doesn't compensate physicians for extraordinary skills or going to extraordinary lengths to treat their patients, Salmon points out, citing two examples:

  • A patient calls a physician office at 4:30 p.m. on a Friday and needs to be seen by a doctor.

"The physician has to make a decision about staying late or sending the patient for emergency care. If the physician is really trying to provide comprehensive service, he might stay late, but if he's being reimbursed on a fee-for-service basis, he's not going to get paid enough to justify missing his son's baseball game," Salmon says.

  • A patient is traveling and becomes ill with an exacerbation of a condition for which his primary care physician has been treating him. He calls his physician's office and is advised to go to the emergency department.

"If the physician takes the time to call the emergency room and discuss the patient's condition with the emergency room doctor, there's no way in our current system to reward him for taking that time and being behind with his other patients for the rest of the day," Salmon says.

Before it launched the collaboration with CIGNA, Dartmouth-Hitchcock was one of 10 medical groups participating in the Centers for Medicare and Medicaid Services (CMS) Physician Group Practice Demonstration Project, now in its fourth year. CMS has assigned Medicare beneficiaries who receive the majority of their care from Dartmouth-Hitchcock to the project.

At the time the CMS program began, the physician practice didn't use the words "medical home" to describe what they did, but that was essentially what they were doing, Walters says.

Nurses who receive training on health coaching, motivational interviewing, and assessing patients' readiness to change serve as care managers for patients with chronic diseases.

They identify gaps in care and conduct outreach calls rather than waiting for the patients to come into the office or the emergency room with an acute care need, she says.

"We began looking for a commercial partner to expand the model of care we were using in the Medicare program and CIGNA stepped up to the plate," Walters says.

The CMS project allowed Dartmouth-Hitchcock to continue to use its infrastructure and care processes with the Medicare population that had originated when managed care was prevalent in the Northeast.

"We had participated in managed care in a true sense of the word until eight or nine years ago when all of the managed care products and reimbursement changed to fee-for-service reimbursement. Being a multi-care practice, we believe that providing both primary care and specialty care provides quality and coordinated care," Walters says.

"We still had the infrastructure from the days of managed care when we had accepted delegated care management and care coordination as part of our managed care agreements. We were practicing in what we believe is a coordinated and efficient way," she says.