By JULIE MINDA
Federal and state governments, private insurers and employers in the U.S. health system want health care providers to increase health care value by taking more of a preventive, population-based approach to care.
Cincinnati-based Catholic Health Partners is moving in this direction by helping its physician practices become patient centered medical homes, as recognized by the Washington, D.C.-based National Committee for Quality Assurance.
CHP wants 70 percent of the 131 primary care practices it owns to be NCQA medical homes by the end of this year — it currently is at about 50 percent. Once it has implemented the model in the majority of the practices it owns in its seven regions in Ohio and Kentucky, the system plans to offer resources to incent private practices in conversions to a medical home delivery structure.
As medical homes, physician practices improve how they communicate with patients, provide more support so chronically ill patients can better manage their conditions and cooperate more effectively with other providers. They also use electronic medical records and data analysis to better understand the health profile of their patient population so they can use preventive measures to keep well patients well, and chronic disease management techniques to improve chronically ill patients' health status.
During an Innovation Forum session at the Catholic Health Assembly in June, two women who are on the team implementing the medical home model will explain how CHP is managing to radically change the focus and scope of physician practices by advancing this population health approach aimed at obtaining the best results for the most people. Presenters Lynne McCabe and Roni Christopher are with the CHP subsidiary, Health Partners Consulting, which is drawing upon the expertise of CHP, CHP's preferred provider organization and managed care company HealthSpan, and outside consultants to prepare CHP to operate under new payment systems arising from health reform. McCabe directs community care coordination programs and Christopher is executive director of care transformation.
It can be very labor-intensive and costly for physician practices to become medical homes. They must install an electronic medical record system, hire one or more care coordinators, free-up managers to attend meetings about the transition and train staff to comply with the medical home standards.
To partially offset these costs, CHP's foundation provided some funding when some of the system's practices became the system's first medical homes. And some of CHP's regional subsidiaries are providing funds to offset some of the costs being absorbed by the CHP-owned physician practices making the conversions to medical homes now. CHP advisors meet with the practices undergoing conversion frequently, consulting on how to adopt the model and training staff.
McCabe said CHP and its physician practices are making these investments to be positioned for change as the government and private insurers shift from fee-for-service to risk-sharing models that reward providers based on the quality and value of care they provide to populations of patients.
While CHP believes that adopting the medical home model prepares providers well for shifts in reimbursement, it can be difficult to convince busy physician practices with tight margins to make the transition.
But physicians respond to data, and, at the assembly session, McCabe and Christopher will explain how CHP got reluctant physicians on-board by demonstrating how the medical home model improves care management, patient outcomes and patient satisfaction.
Proof of concept
CHP's move toward medical homes began about three years ago when Internists of Fairfield, a CHP-owned physician practice in CHP's Mercy Health region in Cincinnati, experimented with adopting NCQA medical home concepts, including using nurses as care coordinators. The coordinators got patients more engaged in their health care, reminding them of appointments, and checking their understanding of — and compliance with — clinician instructions.
The practice's efforts got Mercy's attention because the care coordinators' work was helping to reduce inappropriate emergency room use and decrease hospital admissions and readmissions while also improving patient satisfaction scores. Health Partners Consulting then helped four of CHP's physician offices secure the CHP foundation funding in 2011 to embed nurse care coordinators in the offices. Mercy and CHP have since assisted physician offices throughout southwest Ohio to become NCQA medical homes and provide care coordination.
Initial resistance
Christopher said from a physician practice leader's standpoint, it may not initially appear that there's a good economic case for moving from an illness-based model to a medical home model that emphasizes prevention and aggressive chronic disease management. Even with funding and corporate staff support from CHP, practices incur financial and staff time costs to function as medical homes. Christopher said the practice leaders wonder, "What's in it for me?"
Dr. John Spaccarelli, a family physician with a Mercy practice that became a medical home in 2011, was among those who initially had reservations. "I wasn't sure this was worth the investment (and) I thought it was an attempt to shift responsibility for care to the organization (rather than the patient or payer). I wasn't sure the model would work."
Dr. Anthony Behler is a medical director with the CHP subsidiary HealthSpan and a physician with Internists of Fairfield, one of the first CHP medical homes. Behler, too, had initial doubts — he thought his practice already was proactively managing patient care.
But both doctors have come to see the value in the medical home model. Behler said once he saw how much healthier chronically ill patients were when a coordinator was in contact with them regularly, helping them manage their conditions, he became a convert to the medical home approach.
Proven value
The doctors said that as their practices have made the transition over the last two years, clinicians and staff have seen improved patient care and outcomes — and happier patients — due to the increased engagement that leads to better care, better compliance with doctors' orders and better results.
Spaccarelli said the electronic medical record coupled with the care coordination is a powerful tool for actively engaging with patients and tracking their progress. He said the model also improves handoffs as patients move from provider to provider.
CHP and Mercy's analysis of de-identified patient data from all the medical homes shows that patient satisfaction has increased and patients' self-management of their conditions has improved.
These improvements have had a real impact on patients' lives, Behler said. He recalled a chronic anemia patient who frequently went to the hospital for care before her physician's office assigned her a care coordinator who helped her stay on top of her condition. Behler said that with the care coordinator, the patient "felt she had a place to go, someone to call, and a personal connection to us between visits.
"Before, we didn't have a dedicated person taking on this panel of high-risk patients and staying in touch with them," Behler said. "It's that (stronger) connection to the primary care system that's the biggest influence."
Patient centered medical home standards
For the National Committee for Quality Assurance to recognize a primary care practice as a patient centered medical home, that practice must:
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Be accessible to patients both during and outside of office hours.
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Use patient data for population health management.
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Use evidence-based methods for care management.
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Assist patients and families with self-care.
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Track and help coordinate patients' tests, referrals and follow-up needs.
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Use patient data to measure and improve performance.
Copyright © 2013 by the Catholic Health Association of the United States
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