Medical home model cuts admissions, ED visits

Clinic takes a proactive approach to care

As a result of a patient-centered medical home pilot program based around preventive and coordinated care, Bend (OR) Memorial Clinic's hospital admissions and emergency department visits dropped for Medicare Advantage members of PacificSource Health Plans.

In 2010, the first year of the program, patients in the pilot program had 9% fewer emergency department visits than the previous year and 30-day hospital readmissions decreased by 14%. The clinic's hospital admissions per 1,000 beneficiaries for participants in the pilot project totaled 231.5 compared with the national average of 351 and the Oregon average of 257. Participants in the pilot made 242 emergency department visits compared with a national average of 530 and an Oregon average of 490 per 1,000 beneficiaries.

The program uses a team of physicians, nurses and other staff who collaborate on preventive care and management of chronic conditions with a goal of preventing hospital admissions and emergency department visits. The medical home pilot project focused on 4,000 PacificSource Health Plans members. Medical home-related procedures have been extended to all patients in the clinic's primary care practice. The exception is a care management program for 85 Medicare Advantage patients who are at high risk for hospitalization and emergency home visits.

"We took the concepts of the medical home and coordinated them into the fabric of our organization. Our goal is to provide patient-centered care for all patients from the moment of check-in throughout the entire patient encounter. We emphasize that everybody in the clinic, starting with reception, is responsible for ensuring a positive patient experience," says Josie Lucas, LPN, department manager and medical home project manager.

A proactive approach to care and enhanced communication with patients and other levels of care are major factors in the success of the program, she says.

The clinic's own hospitalist sees patients in the hospital and notifies the primary care staff when they are discharged so the clinic staff can make follow-up calls. Often the calls are made by a receptionist who transfers the call to a clinician if the patient has questions or is experiencing any medical issues. The practice facilitates same-day appointments for patients who need to be seen. The PacificSource Medicare nurse care manager who is embedded in the clinic reviews the daily hospital census list to identify patients who have been admitted, discharged, or seen in the emergency department to facilitate timely follow up.

When clinic patients are treated at a Bend Memorial Urgent Care Clinic, the clinic gets a notification and someone on the staff calls the patient within 48 hours to answer any questions and set up an appointment with the patient's primary care physician if it is indicated.

Licensed clinicians, either RNs, LPNs, or certified medical assistants, review the files of patients before the visit and look for preventive care gaps. A clinician meets with the patient before each visit, discusses the needed services, takes vital signs, and reviews and updates the patient's medication list. Doctors still approve and order the tests and immunizations but the rest of the team does the legwork.

"Every time we see a patient, this is an opportunity to fill those gaps in care and ensure the patients receive all the preventative services they need. This saves time for the providers, giving them an opportunity to spend more time on the problem that brought the patient to the clinic," Lucas says.

The clinic has created a chronic disease registry and mines its data every six months to identify patients who have not had recommended tests or procedures. A clinician calls patients with gaps in care and reminds them to come in for the recommended preventive care.

"We call and have them come in and get preventative care," she says. The clinic facilitates a consultation with an endocrinologist for diabetics with a hemoglobin A1c of over 8. Patients who have an LDL cholesterol level of greater than 100 are seen every six months.

The clinic offers free educational programs for patients with coronary artery disease combined with an elevated blood pressure. When patients are newly diagnosed with hypertension, a LPN educates them face to face and gives them a blood pressure monitor to take home and use for three days to monitor their blood pressure.

"The key is having the multidisciplinary team including the physician, the nurse and medical assistants collaborate on the care and to make sure patients get the preventive services they need to stay out of the hospital and the emergency department," Lucas says.