EBM12: Medical home model proactively brings care to patients, not the reverse
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Traditionally, the ambulatory care environment has been a “cottage industry,” which has been unmeasured and unmonitored, grounded nearly exclusively on trusting relationships, says Lurye. “The standardization of safety and quality is new, and accountability is very new in the ambulatory setting.”
However, certain ambulatory environments, like Lurye’s Elmhurst Clinic, are being converted into patient-centered medical homes.
While there are multiple definitions for the medical home—including from accreditation bodies such as the National Committee for Quality Assurance—some common aspects across all the definitions include team-based, comprehensive, coordinated care with a focus on quality and enhanced access.
To demonstrate some potential benefits of the primary care patient-centered medical home, Lurye referenced the Patient-Centered Primary Care Collaborative report, which found:
- U.S. Air Force: 77 percent of diabetics had improved glycemic control;
- Colorado Medicaid: 96 percent participation in the Children’s Health Insurance Program;
- Ohio Humana Physicians: 22 percent fewer uncontrolled hypertensive patients; and
- Geisinger Health System: 50 percent drop in readmissions.
Access to healthcare comes in several forms, according to Lurye, including acute care and prevention (primary, secondary and tertiary). Traditionally, the patient has always initiated care for herself or himself. However, “access to care 2012-style” calls for more anticipatory involvement on the part of the provider, explains Lurye, which requires true population health management.
In this environment of attempting to manage approximately 70,000 unique patients (like Elmhurst does) through evidence-based medicine, “you have to leverage technology.” He spoke to a few of the technologies that his practice employs to better care for this population.
First, they use automated contact technology (Phytel), which has two components: Remind, which reads the EHR and calls or emails patients about appointment notifications resulting in a very low “no-show rate,” and Outreach, which targets two- and three-step prevention with evidence. To integrate Outreach into the practice, 46 Elmhurst Clinic physicians approved care protocols for primary prevention (adult and child wellness visits or annual OBGYN appointment), secondary prevention (diabetes checkup every three to six months or at least annual lipid profile) and tertiary prevention (follow up on melanoma or bladder cancer).
“Bit by bit, we introduced protocols into the system,” explained Lurye. “While we sleep, the product goes into the EHR to assess which patients are appropriate for an appointment.” Lurye estimated that the the technology brings a couple thousand visits into the practice per month that may not have come into the clinic before.
Specifically, in the 12 months prior to June 30, the automated call system attempted to leave nearly 449,000 robotic messages for Elmhurst Clinic patients. Of those, Remind successfully reminded approximately 193,000 patients for appointments, and Outreach successfully contacted approximately 39,000 patients. The total unique patients with a CPT code following an Outreach call during this period of time were 19,339.
“There is real clinical and economic value in seeking out patients in the community, and not waiting for them to seek you out,” Lurye noted.
In a medical home model, technology organizes evidence and non-physician staff implements a lot of the evidence, he said. “Physicians have way too much coming at them at any one time,” and thus he recommended using physicians to exercise clinical judgment and design interventions that work for each patient.
“Variation is the enemy of quality,” said Lurye, so utilizing internal consensus-based evidence that allows physicians to establish protocols is integral.
The old paradigm for population health is “I will see you if you come,” and the new paradigm is “I am responsible for you. Population health is impossible with paper records,” said Lurye.
Finally, he concluded that practice transformation is aided by technology, informed by evidence and driven by culture—all of which are necessary for a successful medical home.
The conference was produced by Clinical Innovation + Technology and Clinical-Innovation.com. The event was sponsored by Elsevier ClinicalKey.