Medical home: Focus on better communications

Focus is on care coordination

When Blue Cross Blue Shield of Michigan measured the rate of hospital admissions for patients with diabetes, chronic heart conditions, and asthma, the Detroit-based health plan found that hospitalizations for patients being cared for in a patient-centered medical home (PCMH) were 23% lower than for patients treated in other practices.

"If patients have access to a primary care physician, receive better care coordination and better support for self-management, they can be expected to have fewer admissions because they are getting timely, competent care. That's why we think that the patient-centered medical home model is an important component of improving the care for our members and saving costs at the same time," says David Share, MD, MPH, senior associate medical director for health care quality for the health plan.

The program involves 80 physician organizations and more than 8,000 physicians. Of these, 1,200 physicians in 300 practices have achieved the patient-centered medical home designation, based on implementing changes in their practice to meet PCMH criteria and having good results on quality and cost-performance measures, Share says.

The health plan has developed two transaction codes (T-codes) that physician practices can use to bill for care coordination, care management, or self-management training and support.

In the patient-centered medical home model, a primary care physician leads a team of clinicians who work with the physician to make sure that the patient understands and follows the treatment plan and has everything he or she needs to stay healthy and/or manage a chronic disease.

The team varies from practice to practice but may include case managers, social workers, nutritionists, and diabetes educators who make sure that the patient is getting the care he or she needs on a timely basis, so the physician can focus on treating the patients, Share says.

"In a patient-centered medical home model, the physician and his or her staff partner with patients to identify patient needs, set patient-specific goals, and act on the goals and patient needs in a proactive way, as well as reaching out to patients who don't come in for care but who need preventive care or tests and procedures," he adds.

The patient-centered medical home has a focus on care coordination and improved communication between patients and providers, making it a good fit for case managers, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates LLC, a Huntington, NY, case management consulting firm.

"The principles of the patient-centered medical home underscore many of the core elements in case management and are strongly aligned with advocacy and empowerment of patients," Mullahy points out.

Since case managers are dedicated to improving outcomes while improving costs, the patient-centered medical home model offers opportunities for them to work in another practice setting and for case managers to once again be the catalyst for change, she adds.

A patient-centered medical home provides more comprehensive care for patients by freeing up physicians to focus on complex decision making and building relationships with patients, Share says.

"When a physician sees a patient who has three chronic illnesses, he or she has time to focus on the patient's big issues because the nurse, care manager, or social worker has already educated the patient about his or her condition. The physician can spend more time dealing with the patient's complications because someone else has taught the patient how to use a glucometer or explained how to take his medication. When everybody works as a team, the result is always better patient care," he says.

Electronic records are a vital part of a patient-centered medical home, because they allow the physician to identify at a glance gaps in care and other patient needs, adds Carol Cordy, MD, medical director at Community Health Medical Home at Swedish/Ballard, part of the Seattle-based Swedish Medical Center.

"When I go in to see a patient, I shouldn't have to research whether the patient is due for a Pap smear or when she had a tetanus shot. I'm working to have this automatically generated by the electronic record, so I can focus on diagnostics and patient education," she says.

Physicians at the Swedish/Ballard medical home pilot project spend an hour with patients on the first visit and 30 minutes on subsequent visits.

"One of the headaches of medicine is that you constantly need to see more and more patients and spend less time with them. It's a recipe for burnout and for physicians retiring early, because their jobs are too stressful. As we move toward working more efficiently and our healthy patients are automatically taken care of, we can focus on patients who need more time," she adds.

The patient-centered medical home model will help save primary care by ending some of the frustrations physicians feel and preserve the doctor-patient relationship, adds Nicholas Bonvicino, MD, medical director at Horizon Blue Cross Blue Shield of New Jersey.

The health plan has partnered with the New Jersey Academy of Family Physicians on a patient-centered medical home pilot project and pays participating practices a care coordination fee.

"One of the big issues leading to the demise of primary care has to do with trends in reimbursement, which make it more difficult for physicians to practice medicine in the way they may have originally envisioned. This leads to burnout and early retirement," Bonvicino says.

Member surveys sent out by health plans often come back with criticism that the doctor spent too little time with the patient, wasn't receptive to answering questions, and that the patient doesn't know where to go for services, says Bonvicino. Patient-centered medical homes can reduce or eliminate these issues by improving the members' experience and helping them get the services they need and avoid services they don't need, he adds.

"The old concept of having a primary care physician who shepherds patients through the health care system, helps them get the services they need, and avoid services they don't need has been lost," Bonvicino says.

The result is a fragmented health care system with little coordination between providers and frequent duplication of services, he adds.

"People get lost in the system when their providers don't have complete information. As a result, we're paying too much for the care of some patients and too little for the care of others," Bonvicino says.

"The medical home is another strategic tool that case managers can implement to address spiraling health care costs while broadening and expanding the range of services available to a larger population of people," Mullahy adds.

"We have long recognized that episodic intervention doesn't work and that our opportunities to truly make a difference extend beyond discharge planning and need to occur in a coordinated, community-based manner," she says.

Four professional organizations, representing more than 330,000 physicians, define a patient-centered medical home as "a health care setting that facilitates partnerships between individual patients and their personal physician, and when appropriate, the patient's family."

The American Academy of Pediatrics, the American College of Physicians, the American Academy of Family Physicians, and the American Osteopathic Association collaborated on principles that describe the components of the patient-centered medical home.

The principles include: a personal physician who leads a team of individuals at the practice level who take responsibility for the ongoing care of patients; whole-person orientation; coordinated and/or integrated care across all elements of the complex health care system and the patient's community; quality and safety initiatives; enhanced access to care; and a payment structure that represents the value provided to patients.