by Candi Helseth
When her doctor suggested she be admitted to the medical home program at Lakewood Health System in Staples, Minn., Joan Morphew thought, “I don’t need that kind of care.” Morphew assumed a medical home would be like home care and hospice, services provided in their home when her late husband was ill.
Instead, the medical home embraces a team concept where a primary care provider works with other health professionals to ensure that patients receive coordinated, accessible, comprehensive care on an ongoing basis.
Now that Morphew is in Lakewood’s medical home, she understands the concept and appreciates the coordinated care it provides. Morphew is among approximately 500 patients, most with chronic or multiple illnesses, who have been admitted to the program since it opened in 2008. The rural regional center altogether serves about 30,000 people in a 40-mile radius.
Community Care of North Carolina (CCNC), which began coordinating care for Medicaid patients in 1991, adopted the enhanced patient centered medical home (PCMH) program in 1998. Today CCNC covers all 100 counties in the state with 14 networks and 891,000 patients.
“We began with the idea that we needed to provide patients access to a primary care provider, but as we went on, we realized that wasn’t enough,” said Denise Levis, director of quality improvement. “We also needed to support and work with these primary care providers to develop more patient centered care that really included medical home concepts like evidence-based practices and quality improvement measures. Ultimately, our goal is to improve quality of care while containing costs. The medical home has helped us achieve that.”
The numbers and types of health care providers involved in medical home networks vary, but a primary care provider and a primary point of contact—often referred to as a coordinator or case manager—are essential to the concept.
“Every patient has a specific physician, and the care coordinator is familiar with each of the patient’s diagnoses and has direct access to their physician,” said Lakewood Medical Director Dr. John Halfen, who has been a rural family medicine physician for 30 years. “We schedule physicians for longer visits with medical home patients because their problems are more complicated. What we’ve really tried to emphasize with each physician is that the medical home is a different commitment to the patient. Physicians still look at the problem a patient presents when he comes into the office, but they also view the patient’s entire health care situation. What can they do to keep this patient healthy long-term?”
“Patients can call the care coordinator any time they need help or have a question,” Halfen added. “Patients also have email connections directly to their provider. And our physicians keep time blocks open that the care coordinator can schedule if that patient needs to see the provider now.”
Morphew, 69, has chronic hypertension and elevated cholesterol levels. She takes six different prescription medications. “Sometimes I just have a question and I can call the coordinator and get an answer faster because she’s right there,” Morphew said. “It’s easier to get appointments set up when I need them, too.”
CCNC’s case managers identify patients with high-risk conditions or needs, assist providers in disease management education and follow-up, help patients coordinate care and access services, and collect data relative to the patient.
“Case managers are part of the network team and provide support from one delivery system to another,” Levis said. “If the patient is hospitalized somewhere else, the case manager makes sure the patient gets what he needs when he gets back to his home community, things like getting medications filled and setting up follow-up visits with the primary care doctor again. Physicians really like having a case manager embedded in the physical space of that practice. In the more rural areas, we might have five or six clinics with one case manager for several medical homes.”
Having care networks and case managers in the local communities also improves patient involvement, Levis said. “We’re dealing with more than just physical issues. Most of our patients are low-income and many of these counties are very rural. So we do a lot of things to help them get the care they need.”
CCNC and Lakewood invest considerable time encouraging patients to take charge of their own health. Individualized instruction, newsletters, educational sessions and support groups are among their outreach methods. Electronic medical health record systems help staff coordinate care and track patients’ progress.
“Without electronic records, we wouldn’t have a medical home,” Dr. Halfen said. “We’ve incorporated standards for nursing home care, preventative care, quality improvement and other standards into the weekly electronic searches our care coordinator does.”
While it might appear that medical homes are too labor intensive for already pressed rural providers, Dr. Halfen said staffing pressures are reduced because patients are more proactive and get help before problems become as acute.
CCNC has documented significant improvements in cost, utilization and quality measures, Levis said. A 2006 external accounting audit showed that North Carolina’s Medicaid program saved $124 million from what it would have otherwise spent. North Carolina physicians also have a higher participation in Medicaid, Levis said, because the state compensates them more, whereas physicians in many states refuse to see Medicaid patients because reimbursements are so low. CCNC leaders also regularly meet with physician organizations, legislators and other health care leaders to explain and validate the program’s value. “You have to do your homework,” Levis asserted.
Dr. Halfen and Levis believe medical home programs will continue to grow as existing programs demonstrate how patient care improves when facilities implement the Joint Principles of the Patient-Centered Medical Home, which were developed cooperatively by four national physicians’ organizations.
“Chronic patients are seen as the patients that most benefit being in the medical home but in reality, all patients benefit from this type of care,” Halfen said.
Report Examines Medical Homes
The National Advisory Committee on Rural Health and Human Services is examining the medical home concept in a chapter of its 2009 report. Its Medical Homes subcommittee held site visits at medical homes in the United States last year, in preparation for the report. The report will be available on the Committee’s Reports page this spring.
Back to: Spring 2009 Issue