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Patient-centered medical home: Future of health care arrives

By Dawn Brazell | Public Relations | October 21, 2013

Patient Center Medical HomeDr. William Moran (center) does "teach back" with patient Erica Ingram as resident Dr. Chad Kurzynske listens in. Dr. Moran's group will be involved with the new pilot plan rolling out in January that promises to shape health care for the future.
Sarah Pack 

It’s a conversation you might expect in a classroom, but this one is taking place during Erica Ingram's visit with her internist William Moran, M.D.

“So tell me what medicines are you going to take?” he asks about controlling her asthma. She answers correctly, and then he asks more questions about how she’ll handle those times when her peak airflow rate drops.

“This is called teach back,” Moran said, pausing in the question-and-answer session. “What do we teach you, and what can you teach back to me? We have written details here in case you forget,” he said, handing her an instruction sheet.

“That’s why the team approach is great. I’m like Coach (Bill) Belichick (New England Patriots head coach) – let’s make a different play next time to keep her out of the emergency department.”

That teach-back philosophy is one reason Ingram is here at University Internal Medicine (UIM), which practices a patient-centered medical home model in the delivery of health care. The 22-year-old wants to become an occupational therapist and is savvy to the difference in medical models. For example, she likes that they are doing a medication reconciliation to ensure she’s on the best medicines for her condition and that they don’t conflict with each other. She has not only her doctors, but also a pharmacist on her medical team who will review her medications.

Click here to see a larger version of one of Dr. Moran's case studies that shows how a team can divide and conquer to provide better care for patients with complicated health histories. 

“I like to have a holistic approach to my health care,” she said. “I like being a part of a medical team.”

It shows as Ingram pops back answers to Moran. She’s as motivated as her team to manage her asthma as well as she can. This health care model depends on patient participation and empowerment.

This is the future of medicine as health care changes and rising medical costs encourage a move to this style of primary care. It will be the immediate future for thousands of MUSC employees, who may opt into a new pilot program this month based on a patient-centered medical home. The state Budget and Control Board approved MUSC’s collaboration with the S.C. Public Employee Benefit Authority (PEBA) to offer this type of plan to MUSC employees. The pilot will begin Jan. 1 and is expected to run two to three years, providing critical data for the development of plans that can be adopted across the state

Patrick J. Cawley, M.D., MUSC vice president for clinical operations and executive director of the Medical University Hospital Authority, said it’s the perfect timing.

“We were ecstatic about this,” Cawley said. “We’ve had a group here at MUSC working with a group at PEBA since April. They’ve been working very hard, meeting almost every week working out the details of the plan. At the beginning, I thought there was a slim chance we’d have it done for January 2014, but the group worked hard, and they got it done. We want to try this at MUSC, so that’s why we got moving quickly.”

Cost Containment

The reason MUSC is the perfect collaborator with PEBA is that most employees already receive their care at MUSC, Cawley said. The plan offers a way for employees and MUSC to avoid the 10 to 15 percent rise in insurance premium costs in exchange for using the plan.

“These are our own employees, and they are likelier to work with us and perfect our plan. We’re seeing our cost of care go up very fast. We think we have an opportunity to intervene and do something about that. The way this works is we are going to provide financial incentives for the patient to get their care through the patient-centered medical home. It’s less expensive care and better care.”

The primary care physician serves as the hub of a team of care providers in this model. All the primary care parts of MUSC will be involved: Carolina Family Care, General Internal Medicine, General Pediatrics and Family Medicine – and all are or will be certified as patient-centered medical homes before January.

Dr. Patrick J. Cawley 

Controlling rising medical costs is the number one driver of this plan, but not the only one. “The second reason is that as a health care provider, we’re in a very unique circumstance to provide health care in a way that’s innovative and different. A car builder can’t provide health care to their employees but we can,” Cawley said. “The third reason to do it is that we’re the state’s leading educator in terms of medical education. We have to teach the next generation of nurses, and medical students and physical therapists et cetera how to practice medicine that’s better quality at a less expensive cost. There are ways to do that.”

One way is patient empowerment.

“I’m a physician and have dedicated my entire career to quality improvement and continuous improvement,” Cawley said. “We need a feedback loop here and the feedback loop is the patient. We can put this plan together, but we really need to seek input to see if it’s working the way it should be. If it’s not we need to modify and tweak it. It’s called the continuous learning wheel.”

Another driving force is better data. Eighty percent of the health care dollars are spent by 20 percent of the population. In the patient-centered medical care model, the team does triage on its patients by figuring how to better deal with sicker patients so they get the preventive care they need and reduce costs, while still offering easy access to its healthier population.

Cawley said the primary care providers will be looking at the high utilizers, a task made easier by the use of electronic medical records, and doing strategic outreach so that patients with such conditions as diabetes or high blood pressure, for example, get the preventive care they need. “Medical care is incredibly complicated – it’s one of the most complicated things we do across any business in the United States. We simply have not had the tools.”

Now that's changing. Electronic medical records coupled with data make for a powerful way to change the way medicine is delivered.

“Data is absolutely critical. Instead of waiting until the patient comes in with a problem, you do a lot of reaching out. If you don’t have the data, you can’t do the reaching out. It’s data that needs to be monitored to see what’s working and not working and who is not showing up.”

Data Rules

Mention data, and Moran’s face lights up. Trained as an epidemiologist and having extensive experience in a patient-centered medical home model, he knows what a difference data can make as a division director and a UIM physician.

“We need to build experience in this,” he said. “Most people here have never been exposed to a managed-care model. There’s also not a lot of experience within MUSC with managed care, and there’s not a lot of experience with ‘tell me my numbers.’”

Moran said he has gone to average family care doctors and asked what their control rate with blood pressure is for their patients and gotten the response that they think it is “pretty good.”

“I can tell them mine is 69 percent, and I can tell you the patients who are out of control and that we’re working with. Working with data is working with populations. That’s one of the huge things we’ve developed with UIM. We have incredible data management. It’s tough to look good when you don’t know your numbers. You don’t know how well you’re doing.”

On his staff is health economist Patrick Mauldin, Ph.D., who has more than 20 years experience and can be called anytime for data reports. If Moran wants to see what hospital readmissions are for nursing home patients, for example, he gives Mauldin a call and two minutes later he has the data he needs, he said. If he wants to know which patients aren’t showing up for their appointments, he can find that out, too.

LPN Melissa Nolan checks on Erica Ingram's vital signs. Nolan is one of many who are part of the team in a patient-centered medical home model of care. 

“Our clinic manages the folks well who show up, but those aren’t the only ones I’m responsible for. I’m responsible for the ones not showing up. Our folks have to reach out to our patients to get them back in. If you’re not coming into clinic, you’re much likelier to end up in the ED or the hospital. If you cancel or are a no show for an appointment, it dramatically increases your chances of ending up in the hospital, particularly for certain diseases. If it’s ‘I’m too sick to go to the doctor,’ that’s not a good sign.”

The UIM team has two nurse practitioners and/or physician assistants, 11 registered nurses, 11 licensed practical nurses, two certified medical assistants, three PharmDs, two clinical support staff, eight registration and scheduling assistants, 14 faculty physicians and 96 internal medicine residents. Moran has no doubt the team can offer much better care as a team – a team focusing on value instead of volume.

“It’s where the health system is going. It’s value not volume. Currently, we’re set up to maximize patient volume. Employers and health care reform are demanding more value. Patients are looking for better care, not more care. The challenge is how do you array a delivery system to align the providers with a value orientation, not just a volume orientation.”

The team helps to do this. One example is medication reconciliation that is standard at UIM. It’s standard because Moran knows that 25 to 30 percent of new symptoms he sees in a new geriatric patient are medication-related and a third of emergency visits by older patients are medication-related.

“You take this 79-year-old patient,” he said, citing a long list of medical conditions that the patient has and the medications that have been prescribed. The patient has three doctors, one of whom isn’t even local. “He’s not equipped to reconcile this list. Because he’s old and relatively frail, we can hurt him with these meds a lot. That’s this culture of safety. At least I know what’s he’s on, and we reconcile every time in case he was started on a new medication. Someone has to reconcile this list and my job is to figure out if there are drug-drug interactions, drug-disease interactions or if his symptoms are a side effect.”

Thinking Outside the Box

Moran said he and the many others serving on MUSC’s Patient-Centered Medical Home strategy team love the challenge of setting up better health care delivery models. “There are a lot of reasons why people access services the way they do. We have to build a system that patients like to use - and prefer to use – rather than alternatives like the E.R. that are more expensive.”

His nurses have 1,400 patients each to manage, which may sound like a large load, except only 20 percent have health conditions that require frequent care. Seventy percent of the patients are young and relatively healthy. The question for those patients is how to facilitate their access and care since they generally have jobs and busy schedules. One solution is electronic visits, which saves time for the patient and physician. For example, he may have a female patient call in with a suspected urinary tract infection and the nurse can have her drop off a urine sample. The practice calls in a prescription and checks back with her to see if the infection has cleared in a few days. If not, she is brought back in.

“How many electronic visits can I do in an hour? A lot. Then my time is reserved for those really sick patients who need to talk for awhile.”

Unlike other models of family care, patients are a critical part of the team in a patient-centered system. When Moran worked with Community Care of North Carolina, Hispanic patients reported a language barrier in accessing care. The practice there hired bilingual health care providers and watched the emergency visits by this demographic group significantly drop.

In addition to addressing barriers to access to care, the model also focuses on better patient education. “So when you do a foot exam for a diabetic and do education about how to not get an ulcer on your foot, it’s a worthwhile investment,” he said, citing statistics about the costs of amputations on the health care system. “Eyesight is the same way. What’s the cost of blindness? If you can laser a diabetic’s eyes and prevent blindness, that’s a good thing.”

Moran said patient-centered medical homes do provide better care.

“There will be rocks or potholes, but patients have the opportunity to make us better. We have these new patient satisfaction measures. Patients need to tell us what we need to be doing to be better. We need to take that patient feedback and learn from it. We have to be a learning organization.”

Cawley agrees. That MUSC was ready to take on this challenge in a few months is a testament to the learning that already has taken place. A patient-centered medical home strategy team has been meeting for several years to prepare this model, and there’s been a separate group with a large number of enthusiastic supporters working to get the PEBA pilot plan on course, including core team members: Mark Lyles, M.D., chief strategic officer for the MUSC clinical enterprise; Karyn Rae, managed care; Betts Ellis, Medical University Hospital Authority (MUHA); Mark Stimpson and Dee Crawford of Human Resources; David McLean, MUHA Legal Counsel; and Mark Sweatman, MUSC special assistant to the president, Columbia office.

Cawley said the next decade will bring radical changes to health care delivery. Beyond this pilot project, hospitals are going to have massive capabilities when it comes to analytics, data and patient information.

“A lot of this is coming from electronic health records that we’ve put in place as well as that are being put in place across the country,” he said. “Combine this model with the future of genomics and knowledge about our own genes - combine all three of those things - and we’re looking at a very different type of care over the next 10 years and here at MUSC. We feel as a traditional academic medical center, we need to be on the cutting edge of that testing of what works and what doesn’t work. That is what we do best.”



  Related Video

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Dr. Patrick J. Cawley describes why he's excited about MUSC's new pilot plan.

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