The Patient-Centered Medical Neighborhood

Although the patient-centered medical home is a hot topic these days, some organizations are trying to extend that responsibility for care beyond the four walls of any one clinic. Among those taking the community-based approach is the Colorado Beacon Consortium (CBC) in western Colorado.

The CBC is one of 17 Beacon Communities charged by the Office of the National Coordinator for Health IT with demonstrating the effect of investment in health IT in improved process and outcomes.

In rural western Colorado, 33 independent practices with 150 physicians and 200,000 patients are participating in what Patrick Gordon, the Beacon’s program director, calls the “medical neighborhood.”

Population health management is a community-wide effort, he stressed in a recent interview with Healthcare Informatics. “Payers, hospitals, and local public health agencies all have to be involved,” Gordon said. “We have to create a sustainable ecosystem, and just as with the governing structure of the region’s health information exchange (HIE), the emphasis is on devolving leadership to the local community.”

The HIE, operated by Quality Health Network, is at the heart of the Colorado effort. The key to its sustainability, he said, is becoming an efficient aggregator of data with applications that have value for different participants, including payers. “Deployment of those tools need to return value to each player in the HIE.”

Among those applications under development are community-wide patient-centric registry tools that report at the practice levels. “If we get it right,” Gordon said, “the registry functionality is going to allow us to get ideas of gaps in care and target resources and design interventions rather than taking a shotgun approach.”

Another tool being deployed is Archimedes IndiGO, a decision support tool designed for use by physicians, other providers and patients. IndiGO calculates and displays the risk a patient has of adverse events, such as heart attacks, strokes, and onset of diabetes. “It supports patient behavior change and reduction in risk,” Gordon explained.

The CBC also has quality improvement teams that work with practices on lean principles and continuous quality improvement. The teams help physicians and nurses get workflow benefits from the monthly data reports they receive.

Another centerpiece of the project is going beyond initial training to continuous learning and collaboration. Practices themselves break tasks down into smaller components, Gordon noted. “One practice will do diabetes measures. Another will do cardiovascular ones. Then they share how lessons learned about how they did it. The culture creates a demand for data related to performance of the practice.”

Gordon also stressed that that the gains couldn’t be made without payment incentives. “We had to first build a community architecture and pay practices to use the system.” The CBC, which runs until 2013, has $750,000 in funding support from the Rocky Mountain Health Plan to pay clinical teams to work on practice redesign and some funding tied to measured outcome improvements.

“This stresses how important payers think it is,” Gordon said. “Down the road, with the skills and culture built and data aggregation tools deployed, there will be the basis for real payment reform.” The structure will be there for new ways to measure value based on something other than processes, he added. “It won’t be fee-for-service with window dressing.”