“One day, I had two very sick patients – one with pneumonia and another with heart failure and a viral infection. Six months ago, I would have sent them right to the ER. Now, specialists have opened access to us. As a result, I saw the patients on Thursday and the specialists saw them on Friday. Specialists are making room in their schedules for us so patients can be seen in their offices sooner, instead of making the next stop a costly trip to the ER.”
– David Rau, M.D., Rau Family Medicine
This story clearly illustrates the benefits of a patient-centered medical neighborhood (PCMN) for patients and physicians. It explains why eight practices of Columbus Regional Health Physicians are adopting the PCMN model to improve the health of their community, increase efficiency and lower costs.
|The Patient-Centered Medical Neighborhood
strengthens coordination and integration among primary care practices, hospitals/health systems, specialists and other community resources, building on current, proven methodologies and solutions to develop an efficient, coordinated network of health care delivery.
The eight practices recently became NCQA certified as patient-centered medical homes (PCMHs), the first step toward becoming a PCMN. Their next goal is to fully encompass specialty care, expanding opportunities as highlighted in Dr. Rau’s story.
Efforts began when TransforMED selected the Columbus system as one of 15 nationwide to join a federal innovation award project testing the PCMN model. TransforMED, a nonprofit subsidiary of the American Academy of Family Physicians, and a VHA collaborative team offered grant participants expertise in PCMH and PCMN development. They also provided access to software courtesy of Phytel to track patients using their medical records.
“A major employer in town discussed their needs with us and said they wanted their employees to receive care at practices with NCQA certification,” said Joseph Sheehy, M.D., chief medical officer of Columbus Regional Health Physicians. “So when we heard about the TransforMED grant, we thought it was the way to go.”
|Joseph Sheehy, M.D.
Columbus Regional Health
While the health system was already integrated and involved in meaningful use of electronic health records (EHRs), planning and strategy were required to create PCMHs. To direct the project, each practice had a physician champion on a planning committee, and other leaders in each practice often met as well. “Practices were not required to participate, but eight of nine in our system chose to do so,” explained Dr. Sheehy.
The organization needed to avoid hiring new staff or expanding personnel since the grant provided no funding. However, the local hospital foundation covered the cost of four health coaches to help patients with diabetes, COPD and obesity.
Tracy Salinas, M.D., with Doctors Park Family Medicine is referring more chronic disease patients to their health coach and doing more pre-visit planning to improve the effectiveness of each patient visit.
“We are putting more resources toward managing transitions between sites of care,” explained Dr. Salinas. “Every day, we follow up with patients who have been discharged from the hospital, and we’re doing timely medication reconciliation in an effort to avoid readmissions.”
Benefits for patients
“Patients are noticing their care is facilitated better,” said Dr. Rau. “Hopefully, they are finding us better informed about the totality of their care, not just what happens in our office.”
|Tracy Salinas, M.D.
Doctors Park Family Medicine
Dr. Salinas, reported, “Our patient satisfaction results are increasing across the board, but particularly in the area of same-day access.”
The coaches for chronic disease management have been well received by patients. Right now, patients with diabetes and lung disease receive coaching, but soon those with obesity will also be coached.
“Patients need more self-management tools, more follow-up and tracking than we ever realized. We can’t just recommend a treatment regimen and expect patients to follow through,” said Dr. Sheehy. “People with chronic diseases fall off the tracks without ongoing encouragement.”
He noted the encouragement does not need to come from the doctor; if it comes from someone in the doctor’s office – physician extenders or coaches – it can be effective.
Another key element of the PCMH model is the patient registry, available to practices through Phytel’s software. It identifies gaps in care and introduces population-based medicine with a goal of decreasing unnecessary ER visits. “With the registry, I can see all my diabetic patients and where their hemoglobin A1c levels are,” said Dr. Rau.
Dr. Sheehy noted, “For me, the process has provided a snapshot of the eight practices when it comes to tracking and referring patients, allowing for opportunities to develop better processes for information management and follow through on referrals.”
See the next ISMA Reports for Part 2.