Team-Based CareThe Special Care Center operates on the principle of focusing on the small group of patients with an average of two chronic conditions—invited by predicitve analysis or through an application process—who generate a bulk of the costs. The Center has grown its patient population to 2,500 and operates with two full-time physicians and one nurse practitioner, with specialists on retainer. These professionals are complemented by a mix nurses, nutritionists, and mental health professionals who act as health coaches to engage patients on multiple levels.“We spent a lot of time focusing on team-based care,” says Fernandopulle. “If you want to help people, particularly with chronic diseases engage in their health and improve their diseases, it’s a lot of hard work in what you track and what you eat, and instead of depending on doctors to do all that, we hire health coaches, who are from the communities, speak their language, and live their life.”This high intensity care has yieled results generating high satisfaction rates, reduced admissions, ED visits and procedure rates. Patient satisfaction HCAHPS scores for access and timeliness to treatment have improved 30 to 40 percent, largely due to the Center’s same day/sick day policy and longer than average appointments.The Center outperforms national indicators on diabetes, chronic obstructive pulmonary disease (COPD), and cardiovascular patients, and Fernandopulle notes that more than 90 percent of diabetics were under control and had an A1C below 9 percent while he was medical director during the first two years. Festa adds that even now all the Center’s 889 diabetics have a current A1C logged. An onsite pharmacy and an electronic reminder system for pharmacy refills contribute to a 98-percent medication fill rate. In turn, the Center’s readmission rate of 3 to 6 percent is much lower than the national average for 30-day readmission rates of 16.1 percent (for Medicare patients in 2009).Aligned Incentives and IT InfrastructureInstead of emloying a fee-for-service model, these primary care practices develop a global budget or a flat rate per member per month. Partnerships are made with self-insured groups to share costs of operation, and all staff receive bonuses for improved quality. Patients receive waived office visits and prescription copays to join. The Special Care Center started with two payers and has grown its partnerships to nine insurers that now include Horizon Blue Cross Blue Shield of New Jersey and the Medicare Advantage plan. Festa says that due to this model, the average patient’s healthcare spend decreases by 12 percent after the first year of care.The Special Care Center is now looking at other disease states to target that could possibly include a medical home bundle for cancer care or infectious disease. “It’s about reducing the gaps to seamless transitions,” adds Festa. “We’re stiching up the seams so to speak.”The Special Care Center has always been electronic and uses an electronic health record (EHR) from the Westborough, Mass.-based eClinicalworks. What Fernandopulle and his colleagues recognized early on though was that an EHR by itself would not be enough for population health management. Subsequently, a standalone registry (provided by DocSite, now the Detroit-based Covisint) was installed, which AtlantiCare is now mounting throughout all of their ambulatory practices.Because of the difficulty to tailor EHRs and registries and “after getting tired of beating our head against the wall,” Fernandopulle and his team decided to build their own homegrown IT system for Iora Health primary care practices. “Building software in 2011 is not as hard as it used to be,” he adds, “and we can build software that really does what we want to do.”Iora Health has since built a native web app in the cloud using agile software development with a development team making iterations every two weeks. “The focus unfortunately on most EHRs is how do I bill a code higher,” says Fernandopulle. “That is sorta the business model of a typical practice. [EHRs] are very fancy cash registers with a bunch of clinical stuff laid on it. At Irora, we don’t need any of that. We don’t do any billing. We wanted a system that would enable us to better manage a population.”
