Tuesday, June 18, 2013

Primary Care Finds a (Medical) Home

Primary Care Finds a (Medical) Home

Primary Care Finds a (Medical) Home

Joe Cantlupe, for HealthLeaders Media , June 13, 2013

This article appears in the June issue of HealthLeaders magazine.
As the nation pushes toward value-based care, there is an explosive demand to launch medical home models among physicians, hospitals, and insurers. From the patient care side, the emphasis is on refining treatment—especially for complex conditions—and on the practice management side, the impetus is to offset costs through accountable care organizations and other mechanisms.
The idea of the patient-centered medical home is a model for strengthening primary care through reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care. The effort is not only to improve access to care, but also to focus on patients with complex health conditions who need more intensive medical services that are then coordinated among a variety of clinicians.
Healthcare leaders are involved in creating PCMHs in a myriad of ways. Some insurers are partnering with hospitals and physician groups. Some physician groups are developing medical homes on their own. Others are developing ACO structures with incentives for healthcare providers to work together to treat individual patients across care settings, including doctors' offices, hospitals, and long-term care facilities.
Some states are prepping to get these plans in motion within the next few years. It's likely to be a complicated and eventful journey with many potential pitfalls along the way: transitioning to electronic medical records, facing physician shortages, getting a viable patient base, coordinating care, evaluating the need for specialists to care for patients with chronic conditions.
The medical home concept has been around for decades and has gained momentum in recent years as hospitals and healthcare systems focus on value-based quality care, with the primary care practices serving as a significant focal point.
The National Committee for Quality Assurance has recognized nearly 5,000 PCMHs nationwide for coordinating patient care and meeting specific quality standards, and that number is expected to increase significantly. In light of growing concern about primary care physician shortages, many medical homes are offering incentive bonuses for physicians to become involved in their programs.
"What we're seeing now is really a transformative approach," Jonathan Harvey, MD, chief medical officer of Martin's Point HealthCare in Portland, Maine, says of the medical home's role in the transition from fee-for-service to value-based care. Martin's Point includes a health plan and more than 75 primary care providers at nine health centers. "We're seeing a coming together of our ability to manage populations in a delivery system that has enabled primary care to look at communities in a different way," Harvey says. "It's such an exciting time in so many ways."
Like other medical homes, Martin's Point's primary care delivery system provides overall care that includes multidisciplinary teams with care managers and nurses, often focusing on chronic conditions, such as diabetes, coronary artery disease, congestive heart failure, and asthma.
By using electronic medical records and monitoring results, the Martin's Point medical home is improving outcomes and reducing costs. Martin's Point and other healthcare providers are working to engage patients more in their own care, reminding them to take medications, keep their appointments with physicians, and enroll, if necessary, in weight-, exercise-, and stress-management programs.
Martin's Point's patient-centered medical home program has had a noticeable impact, with a 6.2% reduction in hospital readmission rates, with monthly admissions per 1,000 members reduced from 161 in 2011 to 151 in 2012.
There also was a 9.7% decrease in emergency department visits (the rate of ED visits per 1,000 members, 308 in 2011 and 278 in 2012) for patients who were included in the PCMH and Martin's Point insurance program. Those figures compared rates from April and November 2011 to April and November 2012, according to David Stearns, director of informatics at Martin's Point.
Philadelphia-based Independence Blue Cross, which serves 7 million people in 19 states, has established medical homes by collaborating with at least 150 physician practices and other insurers. The program was initiated by the state's Chronic Care Commission in 2007 as a pilot project "intended to change the way care was delivered so we could better manage the chronically ill," says Richard Snyder, MD, chief medical officer for Independence Blue Cross. Over time, it accomplished its mission, he adds.
For years, before working with primary care practices as a team, "we tended to move the needle very slowly—1%, 2%, or 3% a year," Snyder says, referring to improved outcomes. "We had to change the paradigm to better coordinate the care by reducing the number of redundant tests and avoidable admissions, and that coordination started with primary care."
In a review of patients who received care from 20 physician practices, at least 33% of them had patients with poorly controlled diabetes four years ago, says Snyder. By 2013, that figure for those with an A1c of greater than 9% was reduced nearly in half to 18%, he says.
"What we are seeing is that medical homes are moving ahead very substantially, getting to a nearly 20% to 30% improvement year over year," he says. "The kind of coordination and order that is in patient-centered medical homes has resulted in
better outcomes."

Success key No. 1: Amassing physician groups
When Independence Blue Cross began a medical home model in the City of Brotherly Love three years ago, it started coordinating care with 32 physician practices. Within a year, it expanded to more than 170 practice groups, which included more than 1,000 physicians, says Snyder. Those numbers also translated into significantly improved patient outcomes, he adds.
Independence Blue Cross is part of the Blue Cross and Blue Shield Association. IBC established its medical home physician incentive program, the Quality Incentive Payment System, in early 2010 to "attract and retain high-performing" primary care physicians in southeastern Pennsylvania. There were 32 multiphysician practices designated to serve 220,000 patients under the governor's Chronic Care Initiative.
Other insurers, including Aetna, UnitedHealthcare, Keystone Mercy Health Plan, AmeriChoice, and CIGNA, participated. Independence Blue Cross had more members in the practices than the other plans.
The IBC-led program focuses on a medical home model to improve care coordination by relying on an electronic tracking system to evaluate outcomes. Care coordinators use the system to keep tabs on patients with diabetes, heart failure, or blood pressure issues, for instance.
The coordination resulted in notable improvements in compliance with reporting health metrics among physician practices participating in the collaborative. "That's the kind of data that turns the heads of chief medical officers at health plans," Snyder says. In a report from 2008 to 2011, Snyder and colleagues found that "adoption of the PCMH model reduced overall cost for diabetic members by 21% within the first year, driven largely by eliminating inpatient costs, which fell by 44%.
A significant element of the program was the insurer's reimbursement changes for treatment by primary care physicians. Doctors were rewarded for improving quality of care and providing that care in a more efficient manner. The program allowed participating primary care doctors who met their goal numbers to double their reimbursement, and Independent Blue Cross paid out nearly $37 million in 2011, though there was not a specific breakdown in doubled reimbursements.
In addition to earning extra pay for running their practices as medical homes, doctors can earn incentives based on measures such as coordinating cost-effective care, delivering effective care, and prescribing generic drugs. Individual bonuses reached over $35,000 annually based on the level of the medical home achievement.
"We learned that practices weren't looking for health plans to help them with clinical management," Snyder says. "They were looking for people who understand the benefit structure to help their staff identify how a patient's benefits work, so they can organize services—such as durable medical equipment, home-care services, and pharmacy prescriptions—in a way that optimizes the patient's health plan benefit."
The care coordination resulted in improved outcomes in areas such as lowering blood pressure, controlling cholesterol, and educating asthma sufferers. Specifically, the blood pressure levels at lower than 140/90 showed a 45% improvement, from 57% of people with acceptable blood pressure in 2008 to 83% in 2012.
High blood pressure is linked to an increase risk of heart attack and stroke, and has been defined as any number higher than 140/90. The test for LDL cholesterol is used to predict the risk for developing heart disease. The elevated levels of LDL cholesterol can indicate a risk for heart disease, with an optimal reading of less than 100 for those at risk.
According to the Chronic Care Initiative, the tests showed a 60% improvement from 2008, when there were 35% in the desired range, to 2012, when 56% had acceptable cholesterol levels.
Asthma is always a concern. The chronic lung disease can be life threatening, but it is usually manageable so people can live a normal, healthy life. The Chronic Care Initiative established an "asthma action plan" as part of its medical home program to help patients self-manage this condition. There has been considerable impact, says Snyder.
While 53% of patients had their asthma under control in 2008, that increased to 76% in 2012. In effect, physicians use the tool to help asthma patients evaluate their own conditions for better care.
For instance, patients are asked to check their peak flow—a measurement of how fast they can exhale—at least daily, and more often when asthma symptoms appear. If the patient has no symptoms and the peak flow is in the expected range, then the patient is in the green zone and simply takes his or her maintenance medications. Patients may enter the yellow zone, in which some medications are needed. If a patient has a lot of trouble breathing—or is in the red zone—then it is time to call 911.
The medical home model and its coordination of care proved to be a successful plan to control healthcare costs compared to other methods the insurer tried, Snyder says. "Over the years, we implemented disease management plans and outsourced them to other companies in an attempt to get better control over chronic conditions. That didn't work well."
One of the biggest flaws in those disease management plans, as Snyder sees it, was the insurer's failure to have providers—not just the insurer—involved from the beginning of care, from the first phone call to follow-up contacts. "Patient education doesn't really work when a nurse is sitting in a different state, calling on behalf of an insurance company," Snyder says. What does work is when the patient gets a call from a medical professional that he or she has personally met. "That patient feels guilty for not listening to the doctor or nurse."
Success key No.2: Accountable care organizations
Large and small healthcare organizations are teaming up with physician groups to initiate the medical home model within ACOs, with patient engagement as a top priority to manage chronic diseases.
In 2012, Summa Health Network—the Akron, Ohio–based physician hospital organization affiliated with Summa Health System Hospitals—launched NewHealth Collaborative, a medical home within its ACO. NewHealth incorporates the practices of 203 physicians who care for 44,000 patients, says James Dom Dera, MD, FAAFP, medical director of the NewHealth Collaborative. For Summa, as with many other medical homes, a primary focus is on diabetes, a chronic disease characterized by a broad range of metabolic abnormalities.
"Diabetes is one of our top priorities, because it's our No. 1 diagnosis, impacting so many people," says Dom Dera, who also is a physician with the Ohio Family Practice Centers Inc. in Fairlawn, which is part of the ACO. "We said, 'Let's try to find a way under the auspices of the accountable care organization to see if we can start to transform patient care."
Under an ACO, physician groups and hospitals leverage their resources to tap into services ranging from case management to nutrition. "We are a group of docs coming together for a shared goal. We view the patient-centered medical home as the center of our ACO," Dom Dera says. With preventive care as a major focus, the physicians group partnered with Emmi Solutions, a Chicago-based patient engagement communications company, to nudge diabetic patients who need yearly retinal eye exams. Physicians made calls to patients to encourage them to obtain eye checkups.
"It was important that these calls were personal and from the physicians, and the patients' feelings were 'Hey, this message is coming from my doctor,' " says David Littlejohn, RN, quality improvement director of the Summa Health Network. "Still, we weren't sure what the impact would be. But we were very surprised and pleased."
Over a six-week period in September and October 2012, the Ohio Family Practice Centers physician group showed a 13% improvement in retinal eye exam rates, based on 523 patients with diabetes. The percentage of patients contacted by Emmi that either updated their records or scheduled appointments was calculated at more than 22% based on responses from 24 of 105 people.
Success key No. 3: Improved patient satisfaction
Physician groups are developing their own medical home programs and increasing patient satisfaction.
 That is happening at Cornerstone, a High Point, N.C.–based physician-owned multidisciplinary practice of more than 360 doctors and midlevel health professionals in more than 85 locations in central North Carolina, serving a population of 200,000.
 For Cornerstone, improved patient satisfaction has been the result not only of coordinated care but also homing in on patient response to that care. Cornerstone's medical home focuses on recruiting more adult Medicaid and low-income Medicare patients, most of them with complex and costly illnesses.
 Like physician medical home teams elsewhere, Cornerstone employs a support team that ensures longer one-on-one appointments with patients. With the extra time, the health professionals provide in-depth disease education or stress counseling as part of their services, if needed, according to Michael Ogden, MD, chief clinical integration officer at Cornerstone.
 Using electronic medical records, primary care physicians on the support team receive periodic updates about all their patients, enabling the doctors to quickly identify aberrations in blood pressure, blood sugar, or medication reconciliation that might be a concern. Cornerstone also operates what Ogden terms "transformational models" that include the clinics that serve the polychronic patients and provide dietary or social work specialists and psychologists who coordinate care with nurse navigators. "A psychologist spends a lot of time figuring out ways to overcome barriers to good health," he adds.
Cornerstone made its improvements after several failed attempts at boosting patient satisfaction scores, realizing it needed a more concentrated approach to ensure success. So, several years ago, Cornerstone first surveyed patients to understand how they viewed their patient experiences, examining responses from 360 providers in 85 locations, serving a population base of 200,000. They set a goal of improving patient satisfaction scores by 10% each year, he says.
The sample size for the patient satisfaction surveys has been from 250 to 400, Ogden says. "We have been paying attention to patient satisfaction especially the past two years," he adds. "For the entire team the focus is to have the best experience possible."
 Attaining good patient satisfaction only results with continued improvements in the "culture of the primary care practice," Ogden says. That culture focuses on follow-up care, such as "identifying patients who have gaps in care, the diabetic who doesn't have the eye exam or foot exam."
 Cornerstone committed to improving patient relations by paying attention to what may seem like small customer service details. Scripts for phone messages to patients were rewritten. When patients waited in physician offices, employees would come out from behind their desks to notify patients periodically about the delays. New name badges were distributed that prominently showed the first name of a provider.
Ogden says Cornerstone also uses a standardized method developed by Press Ganey to assess patient experience, with the intent of boosting patient satisfaction scores. It established a PEAK (Patient Expectations Are Key) team that continually reviews patient satisfaction scores and aims for improvement, he says.
The PEAK team includes representatives from clinical operations, medical staff, nursing, and "focuses on enhancing the patient experience," Ogden says. As an example, nurse navigators made repeated phone calls to patients to ensure they were taking their medications and keeping their appointments. In one instance, a nurse navigator's persistent questioning of a breast cancer patient who said she wasn't hungry revealed that the patient hadn't eaten for several days. As a result, the nurse immediately assembled a team to collect food to give her.
Physician champion Yates Lennon, MD, heads the PEAK team. Each month, written communications are sent to staff to provide what they term "wow stories, [patient satisfaction] score updates, and constant reminders about the goals," according to Ogden.
Over the past three years, the PEAK team has worked with staff to oversee a continual improvement in patient satisfaction scores. Three years ago, Cornerstone was in the 76th percentile of patient satisfaction, and it reached 90% in 2013, Ogden says. Cornerstone officials saw the need for change after several failed attempts to boost patient satisfaction scores.
Ultimately, to obtain sufficient patient satisfaction, it's important to have the patients engaged, Ogden says. "Folks aren't used to being reached and touched by a healthcare delivery system," he says. "It's engagement when the healthcare navigator helps patients achieve their healthcare goals."
Success key No. 4: Bridging community gaps
In western North Carolina, air quality issues are producing some of the highest rates of asthma in the state, particularly among children, says Susan Mims, MD, MPH, vice president and medical director of the 135-staffed-bed Mission Children's Hospital in Asheville, N.C.
Through Mission Children's Hospital Regional Asthma Disease Management Program, the hospital uses its regional network to provide intensive case management by respiratory therapists to children suffering from asthma. As a result, the hospital has made inroads in bridging care in the community—thereby reducing emergency department use and all-too-frequent hospitalizations among asthma patients, Mims says.
Mission began its program after evaluating hospital admissions and school absences, and calculated the cost estimate for ED visits.
The asthma program uses a multifaceted educational approach to help families understand the causes, signs, and symptoms of asthma attacks and the proper use of medications, and connects families with community resources that can help.
The hospital's program focuses on children who may not have received intervention on a regular basis, Mims says. The children targeted for these interventional services are those with moderate and severe asthma, and they receive clinical services in a doctor's office, at home, or at school or daycare.
 "This work is vitally important, because we target the highest–risk children whose asthma has not been controlled," Mims says.
RADMP activities have contributed to the reduction of asthma-related emergency visits by 85% and hospitalizations by 95%, equaling a total savings of more than $800,000. The estimated cost savings from the ED visits alone was $142,000, and for hospitalizations, it was $687,477, Mims says.
With coordination under the medical home, ED utilization and hospitalizations declined dramatically, Mims says. Before the program was launched, there were 158 visits reported in 2011; postintervention, there were only nine in one cohort of patients, she says. As for hospitalizations, there were 60 pre-intervention and only three after the program started.
To accomplish these clinical and financial results, the hospital coordinated with Community Care of North Carolina, a Medicaid-run program, and area pediatric primary care practices. "There was a big focus to make sure that kids were getting care addressed in primary care offices and to make sure their asthma was being addressed, and that they would not end up in the ED or admitted to the hospital," Mims says.
Primary care medical homes are involved in ensuring that children continue to receive care for asthma—outside the hospitals. Respiratory therapists coordinate with the program to "visit the schools, the child care centers, meet parents, and talk with families," Mims says. "We're trying to prevent asthma attacks by educating and changing the environment so the disease can be managed more effectively."
Reprint HLR0613-7

This article appears in the June issue of HealthLeaders magazine.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.

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