Building the Strategic Medical Home

More than 400 health systems are actively engaged in researching and building the medical home, reports Lisa Bielamowicz, MD, who heads the Medical Home Project for The Advisory Board, which has identified 50 to 60 varieties of “enhanced primary care.” This inquiry is not an idle question for the consultancy and its hospital members. “What we have heard in working with our membership is that the system is not sustainable and that health care will look very different than how it looks now at the end of this decade,” Bielamowicz says. “Enhanced primary care is going to be central to our success with any of the models under consideration.” Speaking to an audience at the recent meeting of the American College of Healthcare Executives on March 20, in Chicago, Bielamowicz reports that her team has identified basic organizational and tactical elements common to 25 of the medical home programs considered to be exceptional, many of which have been up and running for five or more years. With the average primary care practice providing just 55% to 60% of evidence-based care and wait times averaging one month nationwide—and double that in Massachusetts—enhancing primary care is a front-burner issue. She shared the hallmarks of successful medical homes, a blueprint for building one, and a summation of the concept’s value proposition. What Is It? Bielamowicz declined to offer a definition for the medical home, saying, “If you’ve seen one medical home, you’ve seen one medical home.” She did, however, identify four main activities: Comprehensive care. Closing the gap from delivering 55% of evidence-based care to as close to 100% as possible. Patient engagement. Physicians are not the best agents for this activity. Patient access. If patients can’t get in, then the medical home can’t be the hub for health care. Coordinated care. This entails looking at all of the care a patient receives in every setting. Every successful medical home has two common assets: • Care provided by a team of providers: Physicians can’t do it all. • A disease registry that provides patient metric data to track and monitor patients for improved management. Medical homes will be foundational building blocks for accountable care organizations (ACOs), and Bielamowicz suggests the ACO shared savings program is a low-risk way to gain experience in managing patient populations. If you do plan to take the plunge, it is a good idea to map your development to National Committee for Quality Assurance (NCQA) [hot link: http://www.ncqa.org/tabid/631/default.aspx] regulations. Currently, just 39% of medical homes are NCQA accredited, but payors in some markets may require accreditation. Getting Started Bring on the believers first—preferably those who have already implemented an EMR—and assess whether there is a care team already in place or a hierarchy. “You have the zealots, and the groups in the middle: they need to see that their colleagues have jumped in and survived,” Bielamowicz says. “The skeptics need to see the data, so don’t focus on that 20%. Focus on the first two sets.” The ideal physicians to bring on board first are those interested and enthusiastic, but also aligned with the target population. Another important element is that the primary-care physician be engaged with the care team. “Go in and see how the doctor relates to colleagues,” she suggests. “Is there a team or is there a hierarchy? Does she still call him Dr Smith?” The importance of assembling a care team cannot be overemphasized. If the physician was to manage all of the care identified under the previously noted four main activities for a panel of 2,500 patients, he or she would have to work 21.7 hours per day: 3.7 for acute needs, 10.6 for chronic needs, and 7.4 for preventive services, according to Advisory Board calculations. Three Staff Model Options There are three basic options for a primary care medical home staff model, and some medical homes use more than one, Bielamowicz reports. Diffused across existing staff. In this approach, the responsibilities of all current employees are changed to support the medical home. Front desk staff, for instance, can enter data; lower-level staff can experience some increase in job satisfaction. Dedicated staff member. This model centralizes most of the medical home services in a single staff member, usually an RN. Outsourced resource. Health system examples of this option include chronic disease centers of excellence, case management, and centralized scheduling provided at the system or network level to support care functions. Building the Care Team A key tactic in building the care team is bringing everyone up to license. Physicians should only be doing work that requires a medical license, and nurses should not be rooming patients. In most practices—even in a closed model such as Kaiser Permanente—this will entail upgrading job descriptions. A study of RN, LPN, and medical assistant (MA) scope of practice undertaken by Kaiser Permanente Northwestern found that all were functioning at one level lower than their license would indicate, so job descriptions were rewritten and primary-care physicians were educated on what top-of-license practice means for RNs and LPNs. “Most primary-care physicians don’t know what a nurse can do at the top of her license,” Bielamowicz explains. “A key is training the physicians to know how far they can push their people.” In the traditional primary care office, physicians spend the majority of a visit treating acute conditions and referring patients to specialists, with minimal follow-up and little care standardization across patients. In a medical home, the primary-care physician proactively provides standardized chronic care and preventive care, manages and leads all members of the care team, and coordinates with specialists and hospitals to provide continuity of care across the continuum, Likewise, physician assistants (PAs), RNs, LPNs, MAs, and front desk staff see similar transformations of their positions to maximize performance of all staff in a highly coordinated team effort. PAs are seeing patients; RNs are doing patient follow-up, education, and outreach; LPNs are triaging patient calls and leading group visits; and MAs are screening patient needs and reviewing charts, laboratory results, and self-management goals in pre-visit chart review. The Health Coach A key team member is the health coach, whose duties represent a FTE worth of work, Bielamowicz says. The health coach is responsible for: • Disease registry management, • Pre-visit chart review, • Patient education, • Coordinating care across the continuum, • Quality improvement support, and • Facilitating group visits. Bielamowicz recommends using an RN for this key position, because an RN can, for instance, run an anti-coagulation clinic and bill for some care management. In some environments, however, a different solution may be appropriate. “Carondolet built medical homes in areas that had largely Spanish populations,” she says. “They started with RNs and didn’t have success, so they switched to a model with community health workers supervised by RNs.” Key Efficiency Tactics Key efficiency tactics of successful medical homes identified by The Advisory Board include patient stratification and pre-visit planning. Vanderbilt achieved a 25% reduction in labor costs through the use of patient stratification and by replacing its RN health coaches with a team composed of a RN and MA, to whom below-license work can be offloaded. Patient stratification to improve efficiency. At Vanderbilt, group one would include diabetic patients with complications and comorbidities but no care plan, for whom bi-weekly contact was scheduled. Diabetic patients with a complex insulin regimen and undergoing medication adjustments would fall into group 2, requiring monthly contact. Diabetes patients with a simple insulin regimen, no comorbidities, and clinical measures at a safe level would require just biannual contact and therefore fall into group 3. Pre-visit planning. To make every patient visit more comprehensive, pre-visit planning is critical, and good pre-visit planning checklists help. The Advisory Board reports that in the greatest number of medical homes (49%), MAs are the primary owner of pre-visit planning; 24% use RNs; 11% use MDs; and 13% reported that no clinical credential is required to perform pre-visit planning. “If physicians put together a process, then anyone on the care team can do it,” she says. A big question in the medical home community is the optimal size of the patient panel. If it is too large, the quality of care is at risk; too small, and the cost is too high. As of March 2011, The Advisory Board Medical Home Benchmarking Initiative found that panels ranged from 1,071 to 2,333. The mean panel size was 1,983 patients per physician. Some health systems are making aggressive plans to push panels to 10,000 patients. Bielamowicz is dubious about the 10,000-patient panel, but does believe there is the potential to grow beyond the current mean. Kaiser Permanente panel sizes range from 2,300 to 2,500. The Operational Necessities An operational disease registry is the linchpin of the medical home, but many participants in The Advisory Board collaborative have found that their EMR falls short in disease registry: The EMR is better for looking at an individual patient than a patient population and typically unable to perform predictive work. The Advisory Board has identified lists of must-have and nice-to-have features for a disease registry, starting with identifying populations of patients with a particular disease. “Many of our leaders started by building a simple registry in Excel, ” Bielamowicz says, suggesting the inclusion of patient name, last visit, and hemoglobin. “Don’t wait to be able to buy that.” She suggests beginning with diabetes, followed by asthma. Fifty percent of the panel may need a health coach, but most medical homes find it is easier to do pre-visit planning with all patients to enable preventive care. Patient engagement is one of the hardest elements of the medical home to launch, because not every care team member has the skills to do a motivational interview. A place to begin is to actively communicate the benefits of a medical home. “Make it sound like you are giving additional services to the patients,” Bielamowicz advises. “Most of them think they are already getting the care they need; don’t tell them they are only getting 55% to sell it.” Cost and Return Concern about the cost of launching a medical home and the lack of payor support have deterred some providers from taking the leap. An organization in Albany spent seven figures, but another in southern Michigan spent a fraction of that by using open-source disease registries and developing education collaboratives. The Advisory Board has seen costs range from $15,000 to $50,000 per primary-care physician. “Payors are going to start funding this,” Bielamowicz believes. “They’d like nothing more than to keep people out of hospitals.” Some payors already offer incentives to encourage medical home development in the form of IT support, operational support, and even financial support, including care management per-member-per-month fees, 5% reimbursement bumps, and full-on shared savings arrangements. Bielamowicz closed by connecting the medical home to the larger value proposition for the health system. Four key forces are pushing down the average hospital’s 2.2% operating margin: decelerating price increases from all payors, cost pressure, the influx of baby boomers enrolling in Medicare, and case-mix deterioration. To finance the infrastructure necessary for population management, hospitals must raise their margins from 2.2% to 4%. Without any change to the current fee-for-service model, The Advisory Board predicts that reimbursement erosion will put the average hospital seriously in the red by 2021, with negative 16.9% margins. “Hospitals are going to have to pull every lever in the book to get revenue,” she says, adding that profitability will hinge on successful case-mix management. “Keep these patients out of the hospital so that you can keep beds open for more profitable patients.”Cheryl Proval is the editorial director of HealthCXO.