Feature
The Center of Care
SIU Family & Community Medicine Leads the Way In A Powerful Model Poised to Revolutionize Primary Care
Today’s health care is a winding maze of costly fragmentation characterized by self-diagnosis, poor communication, multiple doctors, numerous diagnoses, many medications, duplicate tests and, too often, surprisingly poor outcomes. A new model of care coordinates and integrates care to improve quality and lower costs. It’s called the Patient Centered Medical Home (PCMH), a concept first coined in 1967 in reference to care coordination for children with complex medical problems. Today, the model is poised to revolutionize patient care, improve health outcomes, and lower costs.
PCMH is a team-based model of care led by a primary care physician in which all providers work together, integrating their skills and talents and utilizing enhanced information technology to ensure seamless care using an evidence-based approach. Access, quality, and safety are guiding principles. Communication and information technology facilitate high levels of care. “The concept includes everything primary care physicians do for their patients to enhance access, continuity, comprehensive care, and coordination of care,” says Jerry Kruse, M.D., MSPH, chair, SIU Department of Family & Community Medicine.
A national legislative initiative, PCMH has been called “essential for better primary care” (Annals of Internal Medicine) that can improve chronic care management and build upon technological advances. Experts envision PCMH as a key to reform of the fragmented health care system and as a way to impart a broader understanding of the value of primary care. It has gained support since Barbara Starfield, M.D., of the Johns Hopkins Bloomberg School of Public Health, named the seven principles of PCMH in 2004 (see page 8).
“It’s been a bipartisan belief that the medical home concept should be a centerpiece of all health reform legislation in the U.S.,” says Dr. Kruse, a member of the Council on Graduate Medical Education (COGME), an advisory body to Congress and to the Secretary of Health and Human Services. “The United States spends twice as much on health care as other industrialized nations. Improving the efficiency of care is the only way the U.S. can quickly get the health-care workforce it needs to improve care and lower costs.”
The National Committee on Quality Assurance (NCQA), a private, non-profit organization dedicated to improving health care quality, certifies a wide range of health-care organizations. Its standards are the first and most widely-used formal evaluation of PCMH. Its research shows that “medical homes can lead to higher quality, lower costs, and improve patients’ and providers’ reported experiences of care.”
Several SIU HealthCare offices already have in place principles of PCMH, including a team-oriented approach, whole-person care, and patient-provider partnerships for care decisions. Harald Lausen, D.O., associate professor of SIU Family & Community Medicine, notes that SIU has been ahead of the curve in terms of the PCMH, both in practice and education. He leads the SIU School of Medicine PCMH workgroup, which consists of more than a dozen faculty and staff members from all primary care departments working to expand and further refine the model.
SIU Family & Community Medicine has taken the lead in implementing the dramatic changes in practices, curriculum, and residencies that PCMH requires for the model to work most efficiently. All four Family & Community Medicine residency program practices — Carbondale, Quincy, Decatur, and Springfield— will be recognized for their PCMH efforts by the NCQA by June 2011. Only 1,600 practices in the nation have obtained this recognition, positioning SIU School of Medicine as the go-to model as PCMH gains prominence on the national stage.
Take a look at how SIU Family & Community Medicine is getting that national recognition and taking existing programs to advanced levels.
THE OFFICE OF THE FUTURE
PCMH has been described as The Office of the Future. This may entail elimination of the waiting room and other work flow changes, such as expanding the duties of non-physician staff and interdisciplinary care, as demonstrated by the SIU Family & Community Medicine programs. The Quincy Program has renovated an entire wing of its building for the Office of the Future with bigger exam rooms and a high complexity lab.
In a forward-thinking approach to care, the Springfield program has expanded its interdisciplinary team during the past 10 years to include positions such as diabetes educators, physician assistants, nurse practitioners, nurse midwives, social workers and clinical pharmacists. “We provide better care as an interdisciplinary team. These services are readily available to our patients when needed,” says Janet Albers, M.D., director of the Springfield program. “The PCMH has motivated us to broaden the number of services and the breadth of care.”
PCMH also brings more responsibility for nursing and support staff in managing the medical record and patient education. “This allows physicians to actually see more patients and spend better quality of time with each patient, ultimately providing better care,” Dr. Kruse says.
The medical assistants and LPNs at the Decatur Family Practice Program were scribing and elevating the level of patient care three years ago, with The WOW Project. “We wanted to wow our patients the minute they walked into the parking lot,” says Annette Gilson, family medicine administrator. “PCMH is about patients, and we’ve been focused on the patient for years.”
This includes enhanced communication, as Decatur Assistant Director Susan Klein, M.D., explains. “We are operating as the patient’s medical home. We get the specialists’ office notes so we can coordinate with medication reconciliation, hospital follow up, and any other needs the patient has when they’re not in our clinic.”
The Carbondale program also takes a proactive approach to ensure they receive reports from specialists. With the streamlined office, “I’m not spending time checking on maintenance issues with patients. I can go over test results and see how we can make patients healthier,” says Marci Moore-Connelley, M.D., assistant professor of clinical family and community medicine in Carbondale.
CARE COORDINATOR
PCMH also has helped launch a new position in the health care industry: the care coordinator. “Care coordination is vital to make the medical home work,” says Dr. Kruse. Care coordinators manage care for chronically ill patients and may even accompany patients on health-care visits.
Quincy has had a care coordinator in place for some time. Its first coordinator, Jamie Ferguson, M.A., now works on the Office of the Future project with Assistant Professor Joe Kim, M.D. Medical Assistant Noel Merritt is care coordinator for approximately 30 physicians at the clinic, including Tom Miller, M.D., program director and director of clinical operations. “With our care coordinator, we can maximize physician and patient time together,” Dr. Miller says. “The physician can more effectively listen to patient, evaluate the problem, and make a plan. The nursing staff can gather the patient history and educate the patient and their families.”
In Decatur, Jill Leonard, R.N., is the program’s first care coordinator, managing care for chronically ill patients, including diabetic and hypertensive patients. Peggy Tripani, R.N., is the care coordinator in Carbondale. She has worked in Carbondale for 20 years, but says that as a care coordinator over the past two years, “I can really see a difference in patients.”
Up until now, there hasn’t been a financial incentive for care coordination, but Dr. Lausen notes that “care coordination could result in cost savings and quality improvement for issues such as medication errors, poor communication during transitions of care, and hospital readmissions.” Illinois Medicaid has two programs designed to improve coordination of care, Illinois Health Connect, which makes per-member, per-month care coordination payments and bonus payments for quality improvement, and Your Healthcare Plus, a Medicaid program that hires care coordinators for the most high-risk, high-cost patients. According to auditors, Illinois Health Connect saved $150 million on the Medicaid budget last year. “Over a three-year period, Your Healthcare Plus saved $300 million for the state of Illinois,” Dr. Kruse reports. “When you put the two programs together, in just the first three years, care coordination programs have saved more than $500 million for the state of Illinois — just for Medicaid patients, according to an independent study. Our vision going forward is to implement this for all patients.”
All four SIU Family & Community Medicine residency program practices — Carbondale, Quincy, Decatur, and Springfield — will be recognized for their PCMH efforts by the NCQA by June 2011.
CHRONIC CARE
Care coordinators and technology are vital to the management of chronically ill patients over their lifetimes. “Utilizing technology for evidence-based disease management would help keep these people healthy over time,” explains Quincy Assistant Professor Timothy Ott, D.O. “If we can get at-risk people screened for high blood pressure, hyperlipidemia, and diabetes, we can save insurance companies money and provide better care by getting these people plugged into primary care.”
SIU’s family medicine programs already have achieved success in chronic care management. The Quincy practice was awarded the Diabetes Care Blue Ribbon Excellence Award from Illinois Health Connect, one of few practices in the state to receive such designation. Quincy also received an Award for Excellence from Your Healthcare Plus for quality care in diabetes and coronary artery disease. Carbondale received an Award for Excellence from Your Healthcare Plus for quality care in diabetes.
Decatur’s PCMH project has improved patient outcomes for its top three chronic diagnoses: hypertension, hyperlipidemia, and diabetes. “We also emphasize preventive care services such as mammograms and pap smears,” says Dr. Klein. The faculty and staff have implemented and improved electronic health records, have met the NCQA guidelines for recognition and are adding advanced measures, such as test tracking and reporting.
SIU patients love the integration and collaboration at SIU’s family medicine programs that PCMH provides. When compared to all SIU Healthcare Clinics, the Decatur Family & Community Medicine program consistently scores among the top three departments and often takes the top spot, according to Kathryn Mahaffey, chief operating officer, SIU HealthCare. Decatur’s most recent patient satisfaction survey ranked the program high in satisfaction for the doctor listening to patient and for doctor answering questions. Nursing and medical assistants ranked high for demonstrating courtesy and respect for patients. Patients also reported high satisfaction in ease of getting medical advice after-hours.
Using advanced techniques from an electronic health record (EHR), Carbondale’s program has included advanced PCMH measures, including population management and Point of Care decision support. The offices in Carbondale and West Frankfort began implementing components of PCMH well in advance of the national impetus, and are the first SIU practice to use highly organized EHR reports to provide individual and group feedback to rapidly implement quality improvement initiatives. The practices are also the first to develop primary care patient registries, an essential element for the highest quality of care.
“PCMH has pushed us to take things further,” says Penny Tippy, M.D., director of the SIU Family Medicine Residency Program-Carbondale. “Using the EHR as a repository, we can pull data that goes back 12 months on the most common diagnoses: diabetes, hypertension, and hyperlipidemia.” EHR data also can tell physicians when the patient last had a mammogram, pneumonia vaccine, or colonoscopy. This allows for proactive, preventive care and allows the staff to screen every patient appropriately and efficiently. “Two weeks before a patient’s appointment, a nurse calls them and helps coordinate getting the tests to get them ready for the clinic visit,” Dr. Tippy explains. “It’s really made an impact on patients. We’ve seen dramatic improvements in care.” In just a few months, annual mammograms are up 30 percent and colorectal cancer screenings are up 20 percent.
“Patients feel like we’re really on top of things, that we’re taking better care of them,” says Dr. Connelley. She leads a monthly meeting on various topics to present the data. For example, in January, every physician got a list of
patients who were due for a colorectal cancer screening. The nurses call patients and coordinate screenings. “It’s become a little competitive when the physicians see how many of their patients need the tests. And that’s been a good thing,” she says.
