How to Create a Patient-Centered Medical Home: A Case Study from Coastal Medical

Evidence from around the world has increasingly supported that strong primary care systems lead to better health outcomes at a lower cost, but an estimated 65 million Americans live in areas that do not have enough primary care specialists to support the population.  The patient-centered medical home (PCMH) model is a system created to overcome many of the challenges associated with primary care by facilitating partnerships among the patient, provider(s) and the patient’s family, but the reality of implementing the model into an existing system is complicated, uncharted territory.

Coastal Medical is a primary care-driven accountable care organization (ACO) formed in 1995 with the merger of seven medical practices. Physician owned and governed, Coastal Medical delivers primary care to 120,000 patients through its network of 19 offices and ancillary sites offering lab work, imaging and billing assistance. These efforts did not happen overnight. Coastal Medical embarked on a methodical, in-depth strategic planning process to completely reorganize the way care is delivered to its patients, and recently sent me to Brown University to participate in the Executive Master of Healthcare Leadership program so that I could learn and apply new skills that would propel the process forward even more efficiently.

Healthcare organizations are still trying to identify a prescription of sorts to guide this process, but having been an integral part of the team spearheading these efforts in my own organization, I have seen firsthand which strategies have been most effective. 

Change is organic and must occur from the ground up

To support system-wide change at Coastal Medical, we first had to make sure our vision, mission, strategy, resources, organization and process were fully aligned. Then, we had to ensure the structures in place would support the large-scale changes we wanted to implement. We created office-based leadership teams and committees and invited all employees to participate in reviews of existing processes. This internal perspective became the foundation from which we built our plan. 

Through this process, we confirmed that both employees and physicians supported our PCMH strategy. At the same time, we also learned that traditional tasks in the doctors’ offices didn’t support that model of care delivery. We began to see other clinical tasks that were once considered office-based as having potential for centralization. We also identified that doctors and medical staff were overburdened, which created significant challenges with regard to providing proactive patient care. 

Including employees and providers of all levels in the designing of new systems has given them a stake in our success, empowering them to embrace change and perpetuate excitement. At our recent staff meeting, 22 different staff members spoke before the group of 450 employees to talk about each practice’s individual redesign project. The organization gave out leadership and innovation awards to reward new thinking. The group of 18 award winners included physicians, office managers, secretaries, medical assistants, nurse practitioners, pharmacists and corporate staff.

Focus on the patients

Once it became clear that the organization and those within it were committed to the redesign, the focus shifted to patient engagement. Traditionally, patients have been overlooked as key stakeholders in provider organizations, but putting the patient first is the essence of the PCMH shift. The first step was challenging traditional volume-based care by identifying the need to reach out to high-risk patients before they require emergency care or hospital readmissions. We worked with Johns Hopkins to create the Provider Dashboard, a system that not only informs care providers of those patients for whom they are accountable, but also identifies high-risk patients or patients with conditions that might not be optimally managed in a way that is timely and actionable. 

Coastal Medical also recognized the need to improve patients’ access to quality non-emergency care, so we developed the Coastal 365 clinic, which is open seven days per week, 365 days per year. To further promote wellness, we continuously roll out new initiatives to equip and empower patients with the information they need to become active participants of their care teams.  Currently, we are rolling out a new wellness initiative that will add an educational component to each Medicare wellness visit, which includes educating the elderly about accessing the patient portal, and when to visit the ED versus the non-emergency clinic.

Data are critical for measuring success in real time

Coastal Medical is currently reporting and achieving upwards of 74 quality measures for multiple payers, including a primary care-driven Centers for Medicare & Medicaid Services ACO, and we have patient satisfaction surveys consistently earning scores in the mid-90s. Throughout the process of redesigning our clinical processes, our goal was to engage patients in their care and help them feel more connected to their primary care teams.  The only way to determine whether our efforts were effective was to collect data from the patients themselves. 

Monitoring the data throughout the implementation process is critical because it enables the organization to course-correct before venturing too far down a path that yields poor results. For instance, we were able to determine from the data collected that our Coastal 365 clinic has led to significant reductions in patient visits to hospital ED’s and urgent care clinics. Systemwide, our measurements seem to support that our shift to the PCMH model has been effective, but we recognize that there are always areas for improvement, and the data helps us to pinpoint those opportunities.

Coastal Medical has come a long way, but we are still very much in the midst of a transformation. By adhering to the principles outlined above--perpetuating a culture that perpetuates change, focusing on the patients and analyzing relevant and timely data—we expect continued improvements within the PCMH model.