By BETSY TAYLOR
ANAHEIM, Calif. — When working with physician practices making the transition to patient-centered medical homes, Roni Christopher, executive director of health care transformation at Health Partners Consulting in Cincinnati, compares the process to trying to eat an elephant. Such large projects can only be done one bite at a time, she said.
She and Lynne McCabe, director of community care coordination programs, are among their firm's core group working with Cincinnati-based Catholic Health Partners to establish the medical home model among more than 40 primary care physician practices in Ohio and Kentucky.
During an Innovation Forum at the 2013 Catholic Health Assembly here, Christopher and McCabe provided an overview of how their group engages physician practice leaders, helping each practice move forward with changes while making sure patient care remains the focus.
Health Partners Consulting holds an initial leadership meeting with physicians and their practice manager to discuss steps for establishing a medical home and to set the goals for moving forward. A patient-centered medical home is a health care setting designed to deliver improved care by facilitating partnerships between patients, their physician and other care providers in a coordinated model.
To help staff visualize the change process, Health Partners Consulting has developed laminated posters for private areas in physicians' offices. The posters display the dozens of steps ahead as the practice moves toward becoming a patient-centered medical home.
The consulting group works with a practice's entire team — employees in registration, billing, lab technicians, medical assistants, nurse practitioners, physician's assistants, nurses and physicians — to establish a common vocabulary and style of communicating about procedures that is comfortable for everyone involved. In discussing how a patient-centered medical home cares for a patient with a chronic condition, for example, the consultants start with a chart illustrating 19 typical steps such as reviewing and reconciling the patient's medication before a visit; coming up with a written plan of care; assessing and addressing barriers to meeting a goal of care.
The consultants and members of the physician's practice then discuss each team member's responsibilities and the procedural changes called for under the new model of coordinated care. After the consultants suggest a change and employees try it, they can "love it, like it, or scrap it." If an employee wants to scrap a proposed change, the consultants work with them to find a solution that suits the practice and meets patients' needs.
During the transition, the practice manager is asked to keep a written quality improvement journal, noting aspects of the practice they are trying to change, whether the change is working and why or why not. The consultant group remains in contact with the practice and returns for site visits both to help solve problems and to work with staff members on specific issues.
The consultants let the practice know not every change will go smoothly at first. "When you make it safe for people to fail É you can really leverage some exceptional learning," Christopher said.
Because quality of patient care is the top priority, the consultants also help physicians' practices establish methods for assisting patients who need more than office visits to manage their health issues. One such solution can be assigning a care coordinator.
In a Health Partners Consulting pilot program that ran for about a year and ended in May 2012, each of 300 patients was teamed up with a care coordinator, one of two nurses added to two physician's practices.
McCabe said the care coordinator nurse identified high-acuity patients; working as a health coach and educator, the nurse assisted patients with goal setting and complying with treatment plans that are rooted in evidence-based medicine. The care coordinator got involved in discussions between the patient, the primary care physician and other providers, and managed referrals to a social worker or behavioral health specialist, and other providers, as needed. The care coordinator followed-up frequently with patients over the phone. The care coordinator also conducted home safety visits and visual medication reconciliation, to make sure patients took their medications properly.
On one home visit during the pilot program, McCabe said, the care coordinator nurse learned her patient was combining all her medications into one basket every day and picking out the ones she thought were correct by trying not to take any two that looked alike. The care coordinator worked with the patient to develop a system where the medications were kept separate, and the patient learned to take the correct doses.
McCabe said the care coordinator pilot program showed effective results. The 300 patients in the pilot showed a 51 percent decline in hospital admissions a year later, a 35 percent decrease in readmissions and a 37 percent decrease in emergency room use, she said. After the pilot, the program continued and grew, with 29 full-time equivalent care coordinator positions expected to be filled by year's end, she said.
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