Medical Home: IT Is on the Team

The patient-centered medical home model taps a variety of technologies, entering the care continuum at an earlier stage and potentially providing better integration among providers. However, cultural change can be as big an obstacle as technical challenges, according to early adopters.

“The U.S. healthcare system responds very well to acute needs,” says Donald R. Lurye, MD, CEO of Elmhurst Clinic, based in the western suburbs of Chicago and incorporating 35 primary care physicians (PCPs), 275 employees and more than 50 multispecialty providers. “However, it’s not as good at managing chronic illness or looking at the health of the population. In our medical home model, we have leveraged our EMR and other technologies to manage and track our patients across a continuum that includes preventive, acute and chronic care.”

John C. Rogers, MD, executive vice chair at Baylor Family Medicine, which hosts two practices and nine PCPs in Houston, concurs that IT infrastructure is essential to initiating quality programs. “Having EHRs for population management, as well as secure web access for appropriate patient interaction, is integral to the medical home,” he says. “The current nationwide push for meaningful use [under the HITECH Act] has expedited the awareness of certain quality indicators that can be tracked via various technologies, and communicated across multiple practices.

“Meaningful use will allow this model to become sustainable because more practices will institute these processes in their EHRs and then once they are turned on, they just become part of the routine,” Rogers says.

One well-established program, Geisinger Health Systems’ ProvenHealth Navigator, tracks 10 specific quality goals for 15,310 patients at 11 sites, five of which are non-Geisinger sites, in its medical home model. Geisinger has a systemwide EHR for all ambulatory and inpatient care, which was operational and geared for quality initiatives several years prior to the medical home launch. Thomas Graf, MD, chair of Geisinger Community Practice, based in Danville, Pa., reports that its four-year-old medical home program has resulted in an 18 percent cumulative reduction in inpatient admissions and a 36 percent reduction in readmissions across the study population, as published in the August edition of the American Journal of Managed Care.

How does it work?

In the medical home model, caregivers are encouraged to proactively reach out to individuals before health problems emerge.

Elmhurst has adopted evidence-based telephonic outreach protocols. If a patient is overdue for a mammogram or if a diabetic patient hasn’t been seen within an appropriate time period, that individual will receive an automated phone call requesting that the patient make an appointment. Elmhurst also is participating in a Blue Cross Blue Shield of Illinois (BCBSIL) medical home pilot, in which 20,000 BCBSIL members will be enrolled; two other Illinois practices are also participating. The payor is providing data and clinical tools to track progress and analyze outcomes.  

“This telephonic approach has generated up to 2,500 appointments a month for medically necessary care that might not have occurred otherwise,” Lurye says. The medical home is particularly beneficial in managing chronic conditions, such as hypertension, asthma or diabetes. In documenting diabetic care at Elmhurst, for example, the template now has robust alerts and reminders about steps to be taken, which are integrated with the standard office visit templates, “so the physician is made aware of diabetes issues, regardless of the reason a patient is being seen.”

‘Super Visits’

One aspect of the medical home that Lurye sees as valuable is the opportunity to maximize the value of every encounter with the physician in the medical home. “For example, a middle-aged person with a number of chronic problems or preventive care needs makes an appointment with a PCP for low back pain or a cold, due to the alert system. With the BCBSIL claims-based alert tool, the number of care gaps has started to decrease in this population over the past 10 months,” he says. For the pilot, BCBSIL is distributing enhanced reimbursement for these “Super Visits,” which the payor deems as visits that incorporate preventive care, in addition to acute care.

Similarly, Baylor Family Medicine activated quality indicators for three conditions—hypertension, diabetes and hypercholesterolemia—as well as best practices alerts if a patient requires a tetanus shot, a pneumococcal vaccine or a mammogram. “Once alerts become part of routine practice, the model will be sustainable,” Rogers explains. “Also, non-physicians, such as medical assistants, are beginning to assume more responsibilities with these standing routine orders.”

Through its EHR system, Baylor utilizes e-prescribing and a web-based patient portal, where patients can review their medication list, health history, request refills or send secured messages. Through the portal, physicians can release lab or imaging results to patients electronically.  

ProvenHealth has about 160,000 patients using its portal, MyGeisinger, in which patients can schedule their own appointments, request medication refills, review lab results and ask questions. “Many patient interactions that previously required a phone call can now be performed electronically,” Graf explains.

Physicians at Baylor Family use a uniform clinical template in the EHR for prevention visits and chronic illness visits. “This type of standardization of care takes time for acceptance and integration into routine practice,” says Rogers, who adds that the cultural shift is one of the largest hurdles to overcome, requiring “leadership, sensitivity and time.”

To achieve National Committee for Quality Assurance (NCQA) Physician Practice Communications and Patient-Centered Medical Home Standards (PPC-PCMH), Baylor tracks quality indicators to assess whether its physicians and staff are following the clinical guidelines. “We will extract each indicator by PCP over a three-month period to assess whether we are improving outcomes,” Rogers says.

Geisinger has expanded ProvenHealth across all its practices, serving nearly 250,000 patients. “This type of comprehensive patient assessment requires the attention of everyone involved, including the nurses, patients and the EHR as active members of the team,” says Graf, who exemplified dilated eye exams for diabetics as a sample metric. “Due to the large network of providers with whom Geisinger physicians work, it was hard to track, but about 75 percent of diabetics were forgetting their eye exam annually. After the go-live of the diabetic bundle, one element of ProvenHealth, 75 percent of the diabetic patients had an eye exam annually.”

Geisinger physicians are paid on 80 percent productivity, 20 percent quality and now, due to ProvenHealth, they receive an additional payment. Likewise, the staff is assessed every six months with a site reward system. With the inception of medical home, the staff may receive an additional bonus, based on patient outcomes. “We’re not paying physicians or staff to simply work harder, but instead to work as a team and eliminate variation.”

Team effort

The medical home is really a “team sport” as it engages patients, physicians and the staff, says Lurye. For example, in the Elmhurst diabetes management template, a color-coded classification indicates which tasks are the staff’s responsibility, such as checking vital signs, inquiry about smoking cessation and referrals. The physicians’ tasks are indicated in a different color. “This classification diminishes ambiguity about responsibility, and helps to ensure efficient patient care,” he says.

Rogers notes that adopting the medical home model requires a practice to “reorganize the way the team works, so that the doctor isn’t the one doing most of everything.”

Graf suggests that the staff “is no longer considered an extension of the physician, as they have very specific individual roles to play to create success. We built an electronic tool to support that team delivery of care. Nurses receive alerts around process measures, such as giving immunizations for diabetics, while physicians should only receive alerts about medical decisions and maintaining patient relationships.”

For governance, Elmhurst established a physician quality committee, as well as a separate workgroup that has been working on the chronic illness care template redesign. Collected data are routinely reported to the physician board, which makes physicians aware about the quality of care they produce, according to Lurye.

In the medical home model, this type of transparency can’t be perceived as “a threat to ego, although people could get a pay cut, if they are not performing well,” Rogers adds.

From primary care to acute care

For family medicine and pediatrics, Elmhurst adopted an open-access type of scheduling. “Using this type of scheduling, we demonstrated in our documentation for the NCQA PPC-PCMH standards that the vast majority of patients with acute needs will be seen that day or the next day,” Lurye says. “If a patient needs to be admitted to the hospital, our adult PCPs collaborate with our hospitalist team at Elmhurst [Memorial Hospital]. The hospitalists can access the EMR in the same manner as the office physicians, so they can rapidly see the patient’s background and medication list, regardless of the time of day.”

“Patients who present to an emergency room (ER) are often not in a condition to relay medical history, but if that information is accessible to the treating provider, the team can respond quickly and appropriately,” Lurye explains. “When a patient is discharged from the hospital and returned to outpatient care, there is a unique EMR template created in the patient’s chart. Therefore, during the patient follow-up, the PCP is aware of the information that the hospitalist wants them to have.”

Similarly, Elmhurst Clinic has set up a system with local nursing homes, whereby when the patient is discharged from Elmhurst Memorial, an Elmhurst Clinic physician will accept the patient, allowing the physician to  have access to what happened in the hospital, the patient’s background in the office and can communicate with the office based PCP. “With this, we hope to demonstrate a decrease in readmission rates.”

Unfortunately, not all PCP practices have achieved this level of integration with their regional inpatient facilities. Baylor Family has a “reasonable level of communication” with one local hospital; however, it still requires faxing of paper documents and manual input, says Rogers.

The future

“The medical home will likely be a key ingredient of accountable care organizations [ACOs],” Lurye predicts. “The current menu of pay-for-performance incentives will transform into some type of bundled tripartite payment. The medical home may foster reimbursement for care coordination activities, fee-for-service [models] that promote access and productivity, and incentives reserved for meeting quality and patient satisfactions goals.”

Graf concurs that the medical home is a critical element for ACOs, due to its “similar quality, data, team care and value-based reimbursement as a compensation model.”

It’s a matter of numbers: Currently, the U.S. has 15 million people who are uninsured. “If healthcare reform brings more people into the insured pool, we don’t have enough medical students for primary care,” Rogers says. “Therefore, PCPs will have to care for more patients, and these evolving models of care are becoming more important in figuring out how the entire medical team can share the workload.”