A key initiative to improve patient care and reduce medical costs is the Patient-Centered Medical Home (PCMH) program. This program assists and motivates patients to focus on the key issues that will help improve their overall health. With the help of care managers and nurses, patients are more proactive about managing their healthcare needs. This system makes better use of a physician’s time and allows them to focus on designing a course of treatment for their patients instead of following up on paperwork and talking with other physicians or care managers who may be treating the patient.
Medical facilities like the Blanchard Valley Health System and Prevea Health have successfully implemented PCMH systems and have seen benefits for doctors, nurses, care managers, and patients.
Compiled by Rob Goodman, Contributing Writer
Considering a move to a patient-centered medical home environment? Read what providers making the transition have to say.
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A key initiative to improve patient care and reduce medical costs is the Patient-Centered Medical Home (PCMH) program. This program assists and motivates patients to focus on the key issues that will help improve their overall health. With the help of care managers and nurses, patients are more proactive about managing their healthcare needs. This system makes better use of a physician’s time and allows them to focus on designing a course of treatment for their patients instead of following up on paperwork and talking with other physicians or care managers who may be treating the patient.
Medical facilities like the Blanchard Valley Health System and Prevea Health have successfully implemented PCMH systems and have seen benefits for doctors, nurses, care managers, and patients.
Three experts — Dr. Paul Pritchard and Jody Weisse of Prevea Health and Patricia Beham of Blanchard Valley Health System — share their insights into how they made the move to the PCMH model and the benefits they’ve seen.
Q: When did you begin your transition to a PCMH and why?
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Pritchard: We started a pilot program in 2009 and implemented population health management technology throughout our entire network in 2011. We decided to make the shift to a PCMH because we found that many of our patients came in for what we call “episodic care.” They’d come in once, we’d prescribe a course of action, and then we wouldn’t see them for another six months. The problem was we didn’t know what they’d done during those six months. We wanted to find a better way to manage patients with chronic diseases such as diabetes, high blood pressure, and high cholesterol.
Beham: We launched our PCMH program in January 2010 in conjunction with a major employer and Hancock Medical Group, a local physician association. We expanded the program to our health system employee health plan a year later. The PCMH effort evolved from an earlier project involving the health system, the physician association, and local employers. In that project, we adopted evidenced-based guidelines for care for chronic conditions and measured and reported on performance compared to the guidelines. The medical home program was a logical next step in improving care.
Q: What process and infrastructure changes have you implemented to align your organization with the PCMH model?
Weisse: We had to make changes within our department such as defining the role of the care managers and then backfilling some of their responsibilities by other members of our team. Another change we had to make was having our IT department change security updates for our records management so that our care managers could have access to records when necessary. In addition, our IT team had to work closely with the Phytel team to allow their population health management programs to access our data.
Beham: As a key part of our medical home program, we have had a performance-based physician bonus program since 2011, and we report physician performance regularly against a set of key benchmarks. In order to do that, we needed a technology solution that could aggregate and report data about the medical home’s population and alert providers to take action to improve outcomes and fill “gaps in care” at the individual patient level. Therefore, we implemented a population health management registry from Wellcentive. Another key aligning factor was that the employers we work with adopted “value-based benefit design” for enrollees in their health plan, which eliminates financial barriers to care for enrollees with chronic conditions. That helped align the incentives of the patients and the providers.
Q: What were the biggest challenges you faced?
Pritchard: As a doctor, I found that the biggest challenge we faced was changing the culture of the physicians. Doctors are trained to interact with patients in a one-on-one environment, which gives the doctors a great deal of autonomy. In general, we had to make the cultural shift to more of a team-based approach to patient care.
Weisse: The biggest change was working with the new technology, mainly understanding the new options for tracking patients. I see it as a work in progress to find ways to use the technology to its fullest capabilities.
Beham: Early on, we realized that patient engagement and patients’ self-management of their chronic conditions was a key challenge.
Q: How are you responding to these challenges?
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Pritchard: We tried to make the transition as easy as possible for the physicians and focused on ways to make sure we make the best use of their time. For example, some patients now come in a few days before their appointment to get tests done. That way when the patient comes in to see the doctor, they can discuss the results of the tests and determine the best way to move forward.
Weisse: The two technology companies we work with, Epic and Phytel, helped us implement a system that supports our needs. We’re learning more and more about the capabilities as we move forward, but it’s been a big help with things like prioritizing callbacks. The next step for us is to learn how the technology can be more helpful to the entire team, not just the care managers.
Beham: When we recognized the need to work more proactively with our enrollees with complex chronic conditions and with patients after discharge from a hospital, we piloted a program that embedded a nurse care navigator in two physician practices. After seeing the results from the program, we expanded it to all 17 practice locations early this year with the support of the physicians.
Q: How has delivering care to patients changed under the PCMH model?
Weisse: Patients feel more comfortable contacting and visiting the office. They want to learn from the care managers to make sure they have all of their questions answered.
Beham: We are doing much more outreach and proactive care, and we have seen real improvements in preventive and chronic-condition care rates. We’ve seen an upward trend in primary care visits and wellness exams and a downward trend in “treat-and-release” emergency room visits and admissions.
Q: How have patients reacted to these changes?
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Pritchard: Since transitioning to a PCMH, our customer satisfaction scores have risen, which is a good indicator of the value of making this shift. My sense is that patients appreciate that someone is looking out for them. Similar to the cultural change that doctors need to make, patients have to want to make changes in their lifestyle.
Beham: The feedback we’ve received is that the patients are happy with the changes. For example, patients reported that they see a real difference in their wellness exams, including setting personal health goals with the physician.
Q: What technologies have been instrumental in your PCMH journey?
Weisse: The two technologies we work with, Epic and Phytel, have been very beneficial. We promote the use of our patient portal, which allows our patients to refill prescriptions, and it allows us to gather current information on a patient’s condition. For example, patients with diabetes can update their weight and blood sugar level, which helps with their overall treatment.
Beham: We use the electronic population health registry from Wellcentive to consolidate the claims data, lab data, and clinical data from office visits, which allows us to proactively manage the population, fill gaps in care, and report to physicians on the performance-based bonus program. In addition, we’ve built in alerts that trigger actions for patients based on their age, gender, chronic conditions, and care history. We also actively use the registry to generate standard and customized reports for our medical management committee.
Q: How has your PCMH transition impacted care coordination/patient outcomes?
Pritchard: We’ve seen improvements in screening rates and chronic disease management. My sense is that the patients who have engaged with us on PCMH have appreciated the benefits, since they realize that the clinic and the doctors are looking out for their best interests.
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Weisse: Implementing the PCMH system has shown patients that we care about their needs and are almost like a second family to them. It’s helped us improve things like when we transition our patients from the clinic to the hospital.
Beham: We have seen measurable improvements in outcomes and reductions in emergency department use and hospital admissions. We’ve seen nurse care navigators making breakthroughs with patients, including increased compliance with taking their medications, making changes in their diet, and better adherence overall, by educating the patient about their condition and identifying barriers like not being able to afford their medicine copays and other social issues. The team approach is making a difference.
A key initiative to improve patient care and reduce medical costs is the Patient-Centered Medical Home (PCMH) program. This program assists and motivates patients to focus on the key issues that will help improve their overall health. With the help of care managers and nurses, patients are more proactive about managing their healthcare needs. This system makes better use of a physician’s time and allows them to focus on designing a course of treatment for their patients instead of following up on paperwork and talking with other physicians or care managers who may be treating the patient.
Pritchard: We started a pilot program in 2009 and implemented population health management technology throughout our entire network in 2011. We decided to make the shift to a PCMH because we found that many of our patients came in for what we call “episodic care.” They’d come in once, we’d prescribe a course of action, and then we wouldn’t see them for another six months. The problem was we didn’t know what they’d done during those six months. We wanted to find a better way to manage patients with chronic diseases such as diabetes, high blood pressure, and high cholesterol.
Pritchard: We tried to make the transition as easy as possible for the physicians and focused on ways to make sure we make the best use of their time. For example, some patients now come in a few days before their appointment to get tests done. That way when the patient comes in to see the doctor, they can discuss the results of the tests and determine the best way to move forward.
Pritchard: Since transitioning to a PCMH, our customer satisfaction scores have risen, which is a good indicator of the value of making this shift. My sense is that patients appreciate that someone is looking out for them. Similar to the cultural change that doctors need to make, patients have to want to make changes in their lifestyle.
Weisse: Implementing the PCMH system has shown patients that we care about their needs and are almost like a second family to them. It’s helped us improve things like when we transition our patients from the clinic to the hospital.
