The Patient-Centered Medical Home in Practice

For some medical practices, particularly those in rural areas, the patient-centered medical home (PCMH) is a pipe dream. A progressive concept, PCMHs are designed to bring teams of clinicians together who organize care around patients and track outcomes over time. This model is easier said than done, however, and poses some formidable operational and technical challenges for providers who comfortably operate in the fee-for-service reimbursement environment or are just coming up to speed with electronic health records (EHRs) and other health information technologies (HIT). But for every challenge there is an opportunity, a concept that leaders from Otsego Memorial Hospital (OMH), a fully accredited 46-bed acute care facility and 34-bed long-term care facility in Gaylord, Mich., know all too well.

As a progressive, independent acute care facility, OMH and its affiliated providers deliver quality care and personal service to thousands of patients in north-central Michigan. Looking to improve patient communication and become more sophisticated care managers, two hallmarks of a PCMH, OMH’s 46-provider multispecialty medical group, which includes three rural health clinics, is successfully participating in the nation’s largest medical home project.

Demonstrating Cost Controls, Improved Quality

The National Committee for Quality Assurance (NCQA) is a driving force behind the PCMH model, creating standards and guidelines to facilitate partnerships between individual patients and their personal physicians. However, health plans such as Blue Cross Blue Shield of Michigan (BCBSM) are also embracing the PCMH concept as a way to lower costs for covering at-risk populations. In 2009, BCBSM launched a “value partnerships” PCMH model for providers throughout the state. The program was quickly embraced by OMH leadership, which had already implemented many PCMH features throughout its organization. They were motivated by the exciting prospect of fundamentally impacting care through even greater enhancements to physician practice patterns. The organization was also interested in financial incentives as it successfully followed the program’s four key principles:

Physicians will deliver higher-quality, lower-cost care when utilizing tools that promote patient engagement as well as a team approach for managing their health.
Patients who have around-the-clock access to their primary care physician are more likely to receive the care they need in the appropriate setting, and well as a result decrease their use of the emergency department for non-emergency conditions.
Primary care physicians who effectively manage their patients' chronic conditions may help prevent hospitalizations, thus improving care outcomes and decreasing costs.
Physicians can more effectively manage their patients' health through the use of secure, electronic patient registries and performance reporting tools.

Nearly 7,000 physicians throughout Michigan are actively building patient-centered medical home infrastructure. PCMH-designated physicians earn an enhanced fee for office visits, to compensate them for the extra time and effort required to practice as a medical home. More than 3,000 of these physicians in 994 practices throughout the state—including those affiliated with OMH’s medical group—have been designated as PCMHs based on their progress in implementing capabilities and demonstrating high performance on quality and use measures—competencies that are only achieved though the successful utilization of an EHR.

Technology Drives Progress

A true PCMH benefits from significant technology investment. The real-time collaborative nature of the model, coupled with the need to accurately measure results, means that organizations need to embrace HIT to be successful.

OMH is no stranger to enabling technologies. Having utilized an EHR solution (from Tampa, Fla.-based Vitera Healthcare Solutions) for over six years, the organization is becoming an ever-more sophisticated user of its integrated system-enabled analytics for monitoring and reporting outcomes, which is one of the hallmarks of its PCMH. For example, while many other providers require a separate module for their clinical technology to comply with disease reporting requirements, OMH achieves registry needs within its existing EHR.

OMH is also ramping up its use of a patient portal. In place since 2010, the portal is a bi-directional communications medium that allows providers and patients to interact in a secure environment. It gives individuals the option to electronically access their physicians’ offices 24/7 to request a prescription refill, pose non-emergent medical question or request an appointment, for example. The secure messages are fielded by office staff who respond to the patient either electronically or by phone, according to the individual’s preference.

To spur interest in the patient portal, the organization runs promotional campaigns, providing patients with educational materials explaining the benefits of this medium. The portal has quickly become another pillar of the hospital’s electronic strategy, not only to meet PCMH objectives but also the requirements of the Health Information Technology for Economic and Clinical Health (HITECH) Act’s Stage 2 of meaningful use.

OMH chalks up its technology-related successes to thorough planning to ensure their EHR use complies with meaningful use objectives as well as those objectives of a PCMH. This allows its providers to have accurate and timely reporting, tracking, and trending capabilities, allowing them to better manage care plans and interact with and treat patients from day one.

Assisting in Complex Care Management

With its PCMH in place for the past three years at four practice sites, OMH is also participating in the Centers for Medicare and Medicaid Services (CMS)-sponsored Michigan Primary Care Transformation Project. The effort highlights PCMH activities that are traditionally very difficult for medical groups (namely care management), allowing successful providers to demonstrate how they have been able to overcome these challenges and create successful programs. OMH’s EHR is the platform that complex care managers use to communicate with primary care providers once they receive information about patients with chronic diseases or other conditions requiring additional interaction.

The organization has been able to show how it assists patients with multiple chronic diseases following their care plans and avoid more costly medical services, such as an emergency department (ED) visit. EHR technology allows follow-up with the patient as providers receive electronic notification when a patient has been discharged from the hospital, for example. Office staff will use this information as a platform to engage the patient, which they can then use to intervene when the patient presents for an office visit.

Additionally, PCMH activities have helped OMH staff better link individuals with community resources, such as identifying transportation needs for follow-up care, designed to lower utilization of costly resources.

But perhaps the greatest reward for OMH caregivers is their ability to achieve the true essence of a PCMH, which is creating partnerships between physicians and stronger relationships with patients—all with the goal of elevating healthcare quality and achieving better outcomes. Successfully doing so will ensure that OMH can service its community in the most cost-effective and patient-oriented way possible.