Medical Home: Information, Communication, and Teamwork for Care Collaboration
January/February 2013
Medical Home
Information, Communication, and Teamwork for Care Collaboration
Hospitals now face penalties if too many discharged patients are readmitted within 30 days. This Medicare stipulation in the Affordable Care Act comes in response to expert analysis that indicates lack of discharge planning and poor follow-up care can lead to unnecessary admissions and higher healthcare costs.
A patient-centered, collaborative approach to delivery is intended to provide the planning and follow-up necessary to improve care quality. However, sometimes physicians, payers, and even patients themselves become an obstacle if they fail to function as a team.
Vanguard Medical Group, a 12-provider primary care practice in Verona, New Jersey, recently became part of a patient-centered medical home (PCMH) initiative designed to overcome those barriers. Through better collaboration among providers, payers, and the patient, Vanguard now ensures a more thorough assessment of patient risks and improved quality of care.
Obstacles to Communication
There is no question that changes in reimbursement have altered care delivery. Many primary care practices, for instance, have tried to hold down costs by using medical assistants instead of nurses to take vitals and handle administrative work. This shift has meant the loss of conversations between nurse and patient about the reason for their visit and general health status. Furthermore, primary care physicians (PCPs) with full schedules seldom have enough time to probe a patient’s overall health. As a result, care has become more episodic and reactive.
In addition, communication between PCPs and specialists is often like being on a sports team where players know their positions, but don’t understand their roles within the context of the entire game. Care now seems to revolve around specialists, while primary care is relegated to treating minor conditions—a recipe for disjointed, incomplete care. Within this environment, Vanguard recognized that something had to change.
Pilot Project Success
In a unique provider-payer relationship, Vanguard Medical Group was one of 35 primary care practices selected in 2009 for a diabetes management pilot project with Horizon Healthcare Innovations, a subsidiary of Horizon Blue Cross Blue Shield of New Jersey. It began with a four-month process to obtain designation as a PCMH by the National Committee for Quality Assurance (NCQA). With the designation achieved, the practices quickly saw how effective PCMH could be treating a single disease state. After one year, Horizon asked eight practices, including Vanguard, to participate in an intense PCMH pilot focusing on more wellness and preventive care.
PCPs worked with senior leaders from Horizon on issues such as emergency room utilization, inpatient admissions and patient care coordination. It was an opportunity to reinvigorate primary care while giving payers a way to lower costs by managing care proactively and collaboratively. For example, Horizon empowered PCPs to deliver the right care at the right time by funding care coordinators for each practice. At Vanguard, this allowed better care management, especially for patients with chronic conditions and at higher risk.
Becoming a PCMH, however, was not a quick and easy process. It entailed, for example, a shift in organizational structure from a vertical, physician-centric model to a more horizontal organization that engages all potential team members in change and care management. Another challenge involved looking at new ways of collecting and leveraging data. Even though the NCQA and the Meaningful Use initiative are redefining how practices gather data and generate basic reports, it is still a significant leap for providers to do this on a consistent basis to better manage patient care.
It would be easy for a practice starting on the path to PCMH to become overwhelmed, but it is important to realize at the outset that the road to PCMH is a multi-year process. Incorporating all of the elements of true PCMH requires a commitment to the idea of continuous change. Perhaps the greatest challenge is finding just the right pace at which to evolve.
Best Practices for PCMH
To improve care safety and quality, PCMH team members have learned to recognize the complete circumstances of a patient’s life—not just the presenting condition. Vanguard now works closely with all PCMH stakeholders: other primary care physicians, care coordinators, hospitals, health plans, technology partners, and most importantly, patients. The following are among the best practices now used to dramatically improve patient-centered care:
• Work with health plans, care coordinator networks and technology applications to simplify and unify patient information management. This requires executive sponsorship at the hospital level to involve those people empowered to make changes. For example, ask to have the hospital’s daily census sent to the practice via secure email so that any patients of the practice who were admitted can be identified.
• Coordinate with hospitals to ensure all discharged patients indicate a PCP. Studies at Vanguard found that only about 50% of patients identified a PCP at admittance, making follow-up care more difficult.
• Use technology to streamline patient data. For example, data can show a care coordinator where a patient is on the risk spectrum, which patients have escalating conditions, or which patients have been noncompliant.
• Improve staff communication for a complete picture of patients’ needs—not only medical, but also social, financial, and administrative. A care coordinator at Vanguard was able to prevent possible ER admissions for two PCMH patients by reviewing electronic health record (EHR) data while also bringing intangibles such as empathy, listening skills, community resources, and administrative problem-solving into the conversation.
• Blend people skills, teamwork and technology. Communicate in a way that builds trust and respect, work together to modify processes and use data effectively. In Vanguard’s case, data showed the practice was receiving about one-third of its patient’s discharge summaries. When this statistic was communicated to hospital leaders, they clearly understood the situation and took immediate action to remedy it.
• Reduce unnecessary ER visits by improving access to a provider. This includes providing evening and weekend office hours, an open schedule for Monday appointments, online appointment scheduling, and promptly returned phone calls.
• Look at practice culture. An enlightened leader won’t be effective if the rest of the practice isn’t committed. The team must understand why change is needed, where opportunities exist and what is involved. Effective PCMH cannot be a top-down process exclusively—everyone must be ready, willing, and able to change.
Physician, Patient and Payer Satisfaction
Studies have shown that focused care management for high-risk patients has significant value in reducing the cost and improving the quality of care to those patients. Better communication throughout the entire care continuum—as well as payer incentives that reward high-quality outcomes and more efficient care coordination—are the key.
In the Horizon PCMH program, for example, the outcomes thus far among the 24,000 participating patients have been encouraging. These include: an 8% higher rate in improved diabetes control (HbA1c); 10% lower cost of care per member per month; 26% reduction in emergency room visits; 25% reduction in hospital readmissions; and 21% lower rate in hospital inpatient admissions.
Like everything in healthcare today, Vanguard’s PCMH model is continually evolving. Medical assistants, for instance, currently are training for expanded tasks such as health education and motivational interviewing. The goal is to assist patient compliance while freeing care coordinators to focus on the sickest of the patient population.
Overall, the PCMH model creates better interactions among the PCP, care team and patient. Patient visits are more relaxed and focused, allowing patients to become more engaged in their health and PCPs to provide more complete care. Practice staff is empowered by having more opportunities to get involved with the patients and care processes. Most importantly, the communication and continuity of care fostered by PCMH helps providers and patients experience greater satisfaction, safety, and care quality on all levels. ?
Thomas McCarrick is a board-certified family physician and has been in practice in the Verona–Cedar Grove area of New Jersey since 1985. He is the chief medical officer and CMIO of Vanguard Medical Group, which is a primary care medical group comprised of 10 family physicians, 1 internist/geriatrician, 6 physician assistants, and 3 nurse practitioners. In addition, he currently serves as a school physician for the Cedar Grove Public Schools. Dr. McCarrick is a graduate of Regis High School in New York, the State University of New York at Stony Brook, and the New York University School of Medicine. He may be reached at tmccarrick@townmedical.org.