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Medical home model can be complementary to hospital DP
Model has point person for DP to call
A health care model that seeks to improve quality while reducing costs is attracting more attention lately as the health care reform has made it a priority for pilot project funds.
The patient-centered medical home (PCMH) model, also called simply "medical home," takes medicine back to a previous time with patient care that is focused around a primary care physician (PCP) team structure. The idea is that patients treated in medical homes have their care coordinated by one PCP, who handles all referrals and ancillary care.
The medical home model could avoid 25% of current readmissions, saving $25 billion a year under a scenario in which it's used nationwide, according to a recent Microsoft Health Plan Industry Group monograph on the subject.
"The tenet of the medical home model is the patient would have a quarterback, a relationship with a personal physician and health team that would help navigate the patient through our complex health care system," says Marjie Harbrecht, MD, CEO of Health TeamWorks, formerly the Colorado Clinical Guidelines Collaborative (CCGC) of Lakewood, CO. Health TeamWorks is a nonprofit collaborative that is working to redesign the health care delivery system.
"More importantly, it should keep them healthy and out of the system," Harbrecht says.
From a hospital's perspective, the model ideally will reduce unnecessary hospital utilization, because it will prevent emergency department visits by patients with diabetes, congestive heart failure, or heart disease that is poorly maintained, Harbrecht and other experts say.
"The hospitals agree they don't want to give inappropriate care," Harbrecht says. "They want the appropriate care where it should happen: right time, right place, right care."
The medical home model's goal is to provide continuous, coordinated, comprehensive care for the purpose of improving quality and reducing costs, she adds.
In the siloed, uncoordinated health care system prevalent in the United States, patients see whichever providers they desire, making frequent changes, and no one provider knows everything about the patient's health status.
"Patients can go wherever they want, but no one helps them coordinate care," Harbrecht explains. "So, the patient might show up in the ER with a condition that could have been treated in a lower-cost setting."
Currently, nationwide, 13% of hospitalized patients require readmission within 30 days of being discharged, and one of the chief causes is delayed or inaccurate communication between hospitalists and primary care physicians around discharge, according to the Microsoft Health Plan Industry Group paper.
The medical home model seeks to reverse this trend, having patients think to first call their medical home office, which often provides after-hours access to a care coordinator, when they have a problem.
The model isn't a gatekeeping system like the old HMO model of the 1980s, says Wanda Hanson, RN, MSN, quality and chronic disease manager of Sanford Health - MeritCare in Fargo, ND.
"If the primary care provider (PCP) can treat the patient's diabetes, then that's where we want it treated," Hanson says. "If they're having difficulty, then it's very important to refer to the endocrinologist, and it's the same for cardiology and other specialties, as well."
It's difficult to say precisely how the medical home model will impact a particular hospital, because each type of medical home is handled differently, the experts say.
For example, each medical home patient seen at one hospital after a congestive heart failure (CHF) diagnosis will receive education and follow-up telephone calls from a nurse specialist, says Tina M. Snapp, RN, BSN, CCM, continental division director of case management at Hospital Corporation of America in Denver.
Case managers also can provide discharge care.
"They make sure they have someone in the case management department who is coordinating care to make sure primary care visits are made in the first week of discharge, which is a significant factor in readmissions," Snapp says. "It's amazing how many people who don't have a PCP visit billed after hospital admission are readmitted."
Ideally, the medical home model leads to better communication and hand-offs between providers.
"We now have a home health provider that has very good discharge programs, risk assessments, disease management programs that we, in essence, will be handing off to," Snapp says. "So, we're creating a streamlined discharge process where the home care coordinator or liaison will see the patient before the patient leaves and within specific intervals, including within 24 hours of discharge."
The goal is for the program to make sure high-risk patients are receiving support when they first return home and perhaps for the first 30 days post-discharge, she adds.
With the medical home model, this process includes the continuation of patient education in the home setting and sending information and updates to the PCP office.
"We want to make sure we're all bridged in this, because we know communication is one of the biggest downfalls of this whole process," Snapp explains. (See story on how discharge planning best works with medical home model, below.)
One of the drawbacks of the medical home model is that hospitals receive no financial incentives to provide better care coordination and communication, some experts note.
"The money still goes to the physician, so the devil is in the details of this," says Robyn Golden, MA, LCSW, co-founder of the National Coalition on Care Coordination in New York and director of older adult programs at Rush University Medical Center in Chicago.
"There are no expectations for the hospital," she adds. "It's the medical home where the expectations sit."
Still, there is potential for a good fit with medical home PCPs and hospitals, she notes.
"The medical home has a transition component of making sure people get more integrated into the community and never are admitted in the hospital in the first place," Golden says. "So, there's great potential for case management and a bundled payment."
Some states have moved forward on the medical home model, using it for Medicaid patients or mandating its availability for all insured patients.
For example, the state of Minnesota passed legislation in favor of the model. The medical home rule went into effect on Jan. 11, 2010. Clinics certified in the medical home model will receive a fee per member per month for coordinating care, Hanson says.
Also, in North Carolina, the medical home model is used to improve health care outcomes among Medicaid patients who have chronic illnesses.
There are nearly 1 million Medicaid recipients in North Carolina, and there are 14 nonprofit networks that serve as their medical home, says Denise Levis Hewson, RN, BSN, MSPH, director of clinical programs and quality improvement for Community Care of North Carolina in Raleigh, NC.
These medical homes take care of sick Medicaid patients, but also look for people who have undiagnosed or untreated chronic diseases to provide them with disease management services, Hewson says.
"They hire care managers, who work with the highest-risk and highest-cost patients to bring them disease management," she explains. "They follow them when they come out of the hospital, help with their medications, and make sure the medical home has the information and data needed to manage their population."
For example, the medical home works closely with diabetes patients, following evidenced-based practices, such as having the physician examine patients' feet for numbness, which could signal diabetic neuropathy, leading to insensitivity, ulceration, and even amputation.
"Research shows that if patients come into the exam room and don't take off their socks and shoes, then the physician doesn't see their bare feet or think about examining their feet," she says. "So, the medical home staff make sure the patient's feet are easily accessible and noticeable when the doctor conducts the exam."
Robyn Golden, MA, LCSW, Co-Founder, National Coalition on Care Coordination in New York, Director of Older Adult Programs, Rush University Medical Center, 710 S. Paulina St., Suite 422, Chicago, IL 60612-3814. Telephone: (312) 942-4436. Email: Robyn_L_Golden@rush.edu.
Wanda Hanson, RN, MSN, Quality and Chronic Disease Manager, Sanford Health - MeritCare, Fargo, ND. Email; firstname.lastname@example.org
Denise Levis Hewson, RN, BSN, MSPH, Director of Clinical Programs and Quality Improvement, Community Care of North Carolina, 2300 Rexwoods Drive, Suite 200, Raleigh, NC 27607. Email: email@example.com. Telephone: (919) 745-2363.
Marjie Harbrecht, MD, Chief Executive Officer, Health TeamWorks formerly Colorado Clinical Guidelines Collaborative (CCGC), 274 Union Blvd, Suite 310, Lakewood, CO 80228. Email: firstname.lastname@example.org. Website: www.healthteamworks.org.
Tina M. Snapp, RN, BSN, CCM, Continental Division Director of Case Management, Hospital Corporation of America, 4900 South Monaco St., Suite 380, Denver, CO 80237. Email: email@example.com.