Primary care clinic takes a team approach

Goal is to improve communication

When Carol Cordy, MD, has a concern about a patient, she often asks a nurse to follow up with a phone call to make sure the patient is doing well and to answer any questions or concerns.

"We have a team approach to caring for patients, and our nurses spend time in the care management role. Whenever I feel a patient needs a little extra care, I alert the nurse to make sure the patient understands his or her treatment plans, has gotten his prescriptions filled, and has what he or she needs to stay healthy," says Cordy, medical director at Swedish Community Health Medical Home in Swedish/Ballard.

With headquarters in Seattle, Swedish is a comprehensive, nonprofit health provider with three hospitals and more than 40 primary care and specialty clinics. The Swedish/Ballard primary care clinic is the first Swedish pilot using the patient-centered medical home model of care.

The clinic focuses on expanded access to care, close communication between the patient and the health care team, and providing continuous, comprehensive, and evidence-based care, Cordy says.

Physicians spend an hour with patients during the first visit and half an hour on subsequent visits. Patients always talk to staff when they call the clinic during business hours and, in most cases, can get an appointment within 24 hours.

The clinic opened in the spring of 2009 with no patients and now is providing care for 1,300 patients.

"We want to cap the patient panel at 2,500 so each provider cares for a smaller number of patients than the typical primary care physician. Our bottom line is the health of the patient. The goal is to keep patients in our panel healthy by proactively managing their care. If patients get the care they need when they need it, it will cost less in the long run," Cordy says.

The practice is located in a hospital wing that was remodeled to accommodate a primary care practice.

The clinic opened with four part-time family medicine residents, a front-desk person, a nurse, a part-time faculty physician, and Cordy. Now there are two front-desk staff, six residents, two nurses, a nurse practitioner, two half-time faculty physicians, and a part-time clinic manager.

The nurses and nurse practitioners serve as care managers for the patients. The front-desk staff call patients to remind them of appointments and notify the physician if patients fail to make their appointments.

"One of the goals of a medical home is to utilize a team approach to taking care of patients. Patients shouldn't identify only with their doctor or nurse practitioner; they should know all the people on their health care team, starting with the front-desk staff," she says.

When the practice gets a notice that a patient is in the hospital, a nurse or sometimes a resident or physician calls the day after discharge and goes over medication and makes sure the patient has a follow-up appointment.

The nurses follow up with pregnant patients and mothers of newborns to make sure they aren't experiencing any difficulties.

They make regular follow-up calls with patients on antidepressants to encourage adherence to the medication regimen.

"In the case of patients with depression, studies have shown that if the nurse calls them a week after they begin treatment and checks back in a few weeks, the patients are more compliant," she says.

The practice is just beginning to identify high-utilizing patients and formulate care plans for them, looking to the community to help meet their health care needs.

"We need to go beyond the medical home to the medical neighborhood. It's not just what we do in the clinic but what is going on outside the clinic that helps patients lead healthy lives," she says.

For example, the staff have researched local community services so patients can get into low-cost exercise or diet programs. They work with nearby pharmacies to make sure that patients can get their medications at a low cost.

Technology makes it easier to manage patients and ensure that they are getting the tests and procedures they need, Cordy points out.

Already, the clinic has set up a secure e-mail system so patients can e-mail their health care providers with questions or concerns. It is also using its electronic medical record to identify patients who need extra care management and to communicate with providers at other levels of care.

"With electronic records, if we send patients to a specialist or they go to the emergency department or are hospitalized within our system, it's all automatically on the electronic record. If a patient is seen in the emergency department or is in a hospital in our health system, I'll be automatically notified," she says.

Goals for this year include managing care for high-risk patients with chronic diseases and ensuring that all patients receive evidence-based recommended screening tests and immunizations, she says.

"If we can identify patients with polypharmacy issues, chronic pain, diabetes, and other chronic diseases, we can focus on how to better help them manage their care and keep them healthier and out of the emergency room," she says.

The clinic has set up a model in which many patients pay a monthly fee, rather than fee-for-service. The goal is to have 100% of patients on the monthly payment plan.

The monthly fees include a long list of procedures, tests, immunizations, and annual exams, including disease management for patients with chronic diseases such as diabetes and hypertension.

"We can manage 95% of what patients need in the clinic," she adds.

Patients at the community health medical home have a variety of payment plans.

"We want to be able to take all comers. Many of our patients have no insurance but don't qualify for Medicaid. They can't afford $400 or more a month for an insurance premium, but they can pay the monthly fee," she says.

At present, about 26% of the patients are self-pay and pay $45 for the first family member, $40 for the second family member, and $35 for children.

"The number of self-employed and self-pay patients who have signed up indicates that there is a big need for this kind of practice and that there is a great need for low-cost basic primary care," Cordy says.

Some patients are employed by small companies that can't afford high-cost, comprehensive insurance for their employees but can afford to pay $45 a month for their employees.

A managed Medicaid program has contracted with the practice and is paying the clinic on a monthly basis for its patients. The practice also is working with a private insurance company that has contracted to pay the clinic on a per-member per-month basis.