Continued . . . .
The Center of Care
SIU Family & Community Medicine Leads the Way In A Powerful Model Poised to Revolutionize Primary Care
MENTAL HEALTH
SIU School of Medicine programs are dedicated to bringing comprehensive primary mental health care into the fold of family medicine, and PCMH is helping. The Illinois Children’s Health Care Foundation awarded grants to study innovative ways to address mental health for children and adolescents. Only five Illinois communities received these grants, and SIU School of Medicine programs in Springfield and Quincy received two of them.
In Quincy, the result is the Prevention, Early Detection and Screening of Children At Risk Emotionally (PedsCare) program, located within their Office of the Future. Rhonda Kewney, LCSW, SIU-Quincy Director of Behavioral Science, coordinates resident education in behavioral health and the PedsCare program. “Over the past 18 months, our program has integrated behavioral health with medical care so that patients can come here for all their needs at the same time. Our vision as behaviorists is to fully integrate mental health as part of health, not always a separate visit.” During a routine wellness exam, children are screened for developmental delays and mental illness. The quality of counseling has improved and family physicians can identify more mental health problems. Counselor JoAnn O’Rourke, LCPC, says PedsCare allows for early intervention for ADHD, autism, and self-destructive behavior. The practice hopes to provide a generalized model of the PCMH and reduce hospital mental health admissions.
Participants of Quincy’s PedsCare Program love the in-office counseling and group therapies. One 11-year old who received counseling through PedsCare now has his ADHD under control, thanks to a weekly group meeting, care from a community psychiatrist, and family therapy. He reports, “It feels a lot better to get all A’s and B’s and not get in trouble and sent to in-school suspension.” PedsCare Counselor Stacy Melton, LCSW, says, “He has become a positive role model to other members in the group.” Other young participants say, “I like to come to group to talk,” and “We learn to be nice and use our words,” and “There’s always room for imagination.”
Under PCMH, the integration includes more adults who are screened for mental health issues as well. In the past year, the Quincy clinic has made 1,500 new patient contacts. “Primary care physicians, especially in rural areas, are the only first-line providers, so access to mental health care can be difficult. Kewney and Snyder are teaching residents how to include emotional health in their patient exams. “We are a rural program, and so when our graduates practice in a rural area they will know how to evaluate behavior problems by themselves — and know when to call a mental health professional,” Kewney says.
Janet Albers, M.D., director of the SIU Springfield Family Medicine Program, echoes that statement. She says the fragmented system means mental health issues may go undiagnosed, and the shortage of child psychiatrists means it can take six months for patients to get help. “Providing mental health care in primary care clinics removes some of the stigma of mental health care,” Dr. Albers says. “We need to enhance the mental health care skills of primary care providers in the medical home.” This was the focus of an Illinois Department of Public Health grant that her program received three years ago to embed additional mental health resources within the program while enhancing the resident curriculum. The clinic now formally screens patients for developmental delays, depression in chronic illness, and postpartum depression. Linda Snyder, LCSW, provides psychotherapy and educates residents about mental health issues. Associate Professor in the Department of Psychiatry, Mary Dobbins, M.D., a pediatrician-turned-psychiatrist, provides on-site mental health consults for pediatric patients at the Family Practice Clinic in Springfield. A psychiatrist serving adults will provide services later this year. “The vision for mental health services has always been in place. PCMH has helped us focus,” Dr. Dobbins says.
FOR THE COMMUNITY
Family physicians have always been part of the community, as Dr. Albers stresses. “I remember being trained in these principles when I was a student here at SIU. We recognize the importance of treating patients over time and within the context of the patients’ families, cultures, and communities. The PCMH is guiding us to further the depth and breadth of the care we provide within the community.”
To make care seamless for children and families and promote earlier screening of mental health, the Springfield program is forming strong community partnerships to create a system of care based on the needs of the patient and their families, their communities, and neighborhoods. The program is a key player in the Illinois Children’s Health Care Foundation grant, which the Springfield community received to begin the MOSAIC Project (Meaningful Opportunities for Success and Achievement through Service Integration for Children). The project integrates mental health supports in the clinical setting for patients and families. Dr. Albers explains: “This is part of the medical home — not just within our four walls but how we interface with the community.” Using a medical home model, this neighborhood-based program is forming integrated and expanded mental health programs for children, including those with developmental challenges, at the Noll Pavilion in Springfield. The Hope Institute, the Autism Project, the Continuum of Learning, the Mental Health Centers of Illinois, the Boys and Girls Clubs of Central Illinois, the Springfield School District 186, and many others are collaborating with SIU.
Instead of a clinic-focused effort, the SIU practices in Carbondale and West Frankfort offices have focused on outreach in their community through services to the public schools. In 2006, a grant from the Bureau of Health Professions funded a Care-A-Van to bring physical and mental health care for adolescents in the school districts. A grant from the Illinois Children’s Health Foundation has brought this care to the schools in Carbondale, Marion, Benton, and West Frankfort.
Medical students are learning PCMH and taking that knowledge into the community. PCMH has become the foundation of the third-year family medicine clerkship, as Dr. Lausen explains. “We used to center teaching on the discipline of family medicine; now we focus on patient care through the medical home model.” Refocused lessons include health policy issues, applying evidence-based medicine in real time during patient encounters, population health and prevention principles, quality improvement activities, health literacy assessment, and shared decision-making. “We’re also emphasizing the patient’s viewpoint of medicine through cultural competency,” Dr. Lausen says. “Recognizing the patients’ health beliefs allows physicians to provide better care for their patients.”
Quincy and Carbondale also point to PCMH as a great teaching model. “This is a process that will meet and exceed the needs of the patient,” says Dr. Miller. “We want to teach family medicine residents, medical students, medical assistants, and licensed practical and registered nurses how to deliver this comprehensive care.”
REIMBURSEMENT
Vital to the success of PCMH is a shift of reimbursement to reward quality and outcomes rather than just volume or patient testing. In addition to maintaining current fee-for-service payments, the COGME report recommends added payments of 10 percent for quality measures, and 40 percent in per-member, per-month care coordination payments for care in the medical home. “This would be based on a patient’s relationship with a usual, continuing source of care,” Dr. Kruse says. “Payment would be based on patients getting better or staying healthy, not the number of tests ordered.” Fee for service would remain the same — 50 percent of all reimbursements — based on direct physician-patient interaction.
Having the NCQA designation will aid in reimbursement payments once Medicare moves the model forward. “They will most likely use the NCQA recognition program to identify programs for reimbursement,” Dr. Lausen notes. The NCQA is enforcing stricter standards in the next cycle of recognition, meaning the work of SIU’s workgroup will continue. This year, the programs are working to obtain the top level of recognition — Level 3 — from the NCQA.
Acquiring funding to implement the PCMH model remains a challenge, but primary care physicians such as SIU Internal Medicine Chairman David Steward M.D., say, “We can’t afford not to do it. Our trainees need to learn it so patients get top-notch care. It’s a lot of work to transition, but it’s definitely worthwhile.”
In pediatrics at SIU, Chairman Mark Puczynski, M.D., is looking at grants or help from Children’s Miracle Network to fund PCMH initiatives. He hopes to recruit a coordinator to help develop the model and coordinate care of complex pediatric diseases with multidisciplinary teams. “There’s no question that the PCMH model would be a huge benefit,” Dr. Puczynski says. “We’ve got to incentivize the model and shift reimbursement. We’ve got to persuade the insurance companies and state and federal officials to provide reimbursement for coordination of care.”
MAKE OR BREAK
As the PCMH movement gains momentum, numerous research projects are measuring the impact of this delivery of primary care. In brief, PCMH works. Community Care of North Carolina, a state-wide network of medical homes, saw a cumulative savings of $974.5 million over six years (03-08), a 40 percent decrease in hospitalizations for asthma and a 16 percent decline in emergency department visits. In Michigan, Genesee Health Plan saw a 50 percent decrease in emergency department visits and 15 percent fewer in-patient hospitalizations with total hospital days per 100,000 enrollees 26.6 percent lower than competitors. The results conclude: “Health systems built on a solid foundation of primary care deliver more effective, efficient and equitable care than do systems that fail to invest adequately in primary care” (Grumbach, Grundy; Outcomes of Implementing Patient Centered Medical Home Interventions Patient Centered Primary Care Collaborative 11/16/10).
A study from the Johns Hopkins Bloomberg School of Public Health found that almost half of office visits to non-primary care physicians could have been cared for better in a primary care office. “Coordinated care is imperative,” Dr. Kruse emphasizes. “Primary care physicians and consulting specialist physicians must have rapid, effective means of communication and data transfer, and all members of the health care team — including nurse practitioners, physician assistants, nurses, medical assistants, and counselors — must use their talents in an optimal fashion at the top of their skill levels.”
Dr. Kruse and others hope that the PCMH may help turn medical students, nurse practitioner students, and physician assistant students toward careers in primary care. The percentage of students in all of those disciplines choosing primary care careers has declined significantly in the last decade. “Only 15-20 percent of medical students are choosing primary care nationally,” Dr. Kruse reports. “And the number choosing careers in family medicine at SIU has declined in the past three years.” Still, SIU School of Medicine’s fourth-year students choose primary care careers higher than average — about 44 percent — compared to the nationwide 32 percent.
PCMH may help turn the tide toward primary care. The AAMC reported that more of this year’s graduating students will train in primary care specialties; family medicine experienced the largest growth, increasing 11 percent from last year.
Ultimately, PCMH is one piece in the rebuilding of primary care in American health care. Dr. Kruse and the SIU Department of Family & Community Medicine are dedicated to helping medical students, legislators, and the public understand the value of primary care for patients, families, and the health care system. “The evidence is clear,” Dr. Kruse says. “PCMH improves outcomes, lowers costs, and makes practices more enjoyable for health care professionals and for patients. It’s a make or break model for primary care.”