Medical Homes Provide Coordinated Care for Chronic Conditions

by Candi Helseth

Sarah Jones* repeatedly brought her baby to a local emergency room because it suffered from chronic asthma. Jones assured the physician that she was keeping her home clean to minimize the baby’s asthma attacks. In fact, a local case manager with one of the networks in Community Care of North Carolina (CCNC) visited the home and found it spotless. But, as she visited with Jones, she learned that the mother was proudly cleaning her home with bleach—so much bleach that it was triggering the baby’s asthma attacks. Since that home visit, Jones’ emergency room visits have stopped.

Lauren Smith*, a patient with diabetes, heart disease, hypertension and high cholesterol, takes several prescription medications and is also an alcoholic. A CCNC case manager began working with Smith to help her use her medications properly. As the case manager gained Smith’s trust, she also got Smith to promise to eat whenever she drinks because eating helps stabilize her blood sugars. As a result, Smith’s frequent visits to the emergency room for diabetic shock have greatly decreased.

Patients with chronic conditions are better managed in medical homes because of the long-term coordinated approach, said Denise Levis, CCNC director of quality improvement. This is especially important in the United States because 45 percent of Americans have a chronic medical condition, according to a report on the medical home model from the Deloitte Center for Health Solutions in Washington, D.C.

“A lot of our Medicaid patients were using ER for their primary care,” Levis said. “People with chronic conditions are really the ones that benefit the most being in the patient centered medical home (PCMH) because their care was very fragmented before.”

Patients with multiple chronic illnesses account for as much as 75 percent of total health care spending. Within Medicaid, 5 percent of beneficiaries—80 percent of them having three or more chronic conditions—account for up to 50 percent of total Medicaid spending. Chronically ill patients are also often on multiple medications, and improper usage or over-medication can exacerbate chronic conditions. Pharmacists are integral members of CCNC’s networks, monitoring and evaluating patients’ medications. Levis said CCNC local network staff members also work directly with patients, teaching them how to properly take meds and better manage their disease.

CCNC networks remind patients when they need appointments and encourage them to come prepared. Patients are asked to write down their questions prior to the appointment, bring all their medications and keep personal records. If they have needs outside the medical realm, such as lack of transportation to an appointment, CCNC network case managers make appropriate referrals or arrangements.

CCNC has developed quality improvement initiatives for management of chronic patients with asthma, diabetes and heart problems that are available online at the CCNC webpage, under the Quality Improvement/Program Wide Initiatives tabs.

* Names have been changed to protect patient privacy.

Back to: Spring 2009 Issue