Unifying a Patient-Centered Medical Home

In upstate New York, where an aging population of primary care providers is leaving the workforce faster than new PCPs can be recruited, community leaders have founded the Adirondack Region Medical Home Pilot Program to increase emphasis on primary, preventive, and chronic care, as well as improving patient communication. Coming together as a patient-centered medical home (PCMH) however has not been without its challenges, which include interfacing clinical information systems and aligning incentives between payers and providers.In 2009 the CEOs from the three major healthcare systems in Upstate New York, Adirondack Medical Center, Hudson Headwaters Health Network, and CVPH Medical Center [Champlain Valley Physicians Hospital], met to address the dwindling number of PCPs in the area. The program was designed to improve the care coordination and management of patients through a PCMH model, with the implementation of interoperable health IT.Before the Adirondack Region Medical Home Pilot officially kicked off in January 2010 as a five-year, $9 million joint initiative of medical providers, Medicaid, and seven private insurers, New York State antitrust legislation had to be passed. A Medical Society of the State of New York (MSSNY) grant provided early technical and infrastructure assistance and capital funds, while consulting services from East Point Health helped bring guidance to the project. In July 2011, Medicare joined the pilot for three years.More than 200 clinicians are organized into three geographic pods across the Adirondack North Country region—the Northern Adirondack pod (Plattsburgh and surrounding communities), Tri-Lakes pod (Saranac Lake and surrounding communities), and Lake George pod (Lake George and surrounding communities). Pods have weekly, monthly, and quarterly calls and meetings to update each other and share best practices.“One of the things that really has been highlighted is you have such a huge region that covers the entire northeast portion of New York State, and we’re really working together, even though we’re not necessarily integrated, and we’re not in any way affiliated,” says Karen Ashline, director, Northern Adirondack Medical Home Project. “It’s just the fact that we’re sharing information about how to better provide transitions of care and how to cut costs over a wide region.”

Karen AshlinePilot practices have an increased emphasis on primary and preventive care, improved coordination of care and management of chronic diseases, improved communication with patients–including patient reminders for check-ups and screenings—and use electronic health records and electronic prescribing to adhere to quality and safety standards. Last December, all 31 primary care practices in the program, which include hospital and non-hospital employed physicians, were recognized as Level 3 Patient- Centered Medical Homes—the highest level achievable—from the National Committee for Quality Assurance (NCQA). Physicians receive incentives for coordinated care, while some of the incentives funnel back to the pod to provide for shared care management, social work, and IT services.“Those small practices were really struggling, so this incentive that they’re receiving to now participate in a patient-centered medical home, has both helped them stay afloat and stay in our community,” says Ashline, “but also provide some additional support for their patients.”Embedding Transitional Care NursesTo aid in its mission to better coordinate care, the Adirondack pilot utilizes transitional care nurses to give post-hospital discharge support to patients to aid in preventing readmissions. At CVPH, there are three transitional care nurses that identify patients that need help, reach out to their PCPs, work with the pharmacy on the medication reconciliation process, and do home visits as needed. “We have reduced the preventable readmission rate at CVPH,” says Ashline. “That’s probably where we are most robust.”The Adirondack pilot also focuses on chronic care, including diabetes, hypertension, and coronary artery disease, which were chosen based on region-specific clinical and insurance claim data. In the last three months, Ashline says two care managers have been embedded in practices to focus on diabetics, while six staff members have been trained to be chronic disease self-management peer-to-peer trainers.To keep up with the IT demands of the pilot and allow connection to the Health Information Exchange New York (HIXNY), Mountainview Pediatrics had to switch EHR providers (to the Poway, Calif.-based MDsuite, which they had on the practice management side already) in August 2011. This pediatric practice, like the others in the pilot, focuses on asthma and childhood obesity.“We can now pull all the kids who have a BMI greater than 85th percentile and are considered overweight or obese, and we can target those kids,” says Heidi Moore, M.D., co-owner of Mountainview Pediatrics. She adds that her practice sponsors several obesity community programs like a teen “Biggest Loser” and other healthy eating programs. For asthma prevention, Mountainview Pediatrics uses clinical decision rules to identify the chronic asthmatics and make sure they are taking preventative medications. The Northern Adirondack Pod has also had nurses receive asthma certification to help with patient education.

Heidi Moore, M.D.Within the Northern Adirondack Pod, the five pediatric offices use a 24-hour call service out of Cleveland, Ohio, to give a layer of service for parents to use before utilizing the ER, which Ashline believes has diverted a significant number of ER visits.Mountainview Pediatrics reaches out to its patients in a variety of ways, including its Facebook page and a patient portal. To connect to the community, the practice posts health lectures, drug recalls, and other customer relation items to its Facebook page. “We have this mass community campaign called Sick Happens, where we’ve tried to create a community dialogue about emergency room visits—what’s appropriate for ER visits and what’s appropriate for primary care visits,” says Moore.Patients can request immunization forms, request appointments, and request medical records through the Mountainview portal. Moore hopes in the future to have additional functionality to route all messaging to the patient chart and to have some communication be more easily routed to the front office staff.Quality Reporting ChallengesPhysicians are capturing 45 measures across six disease states in their practices, says Ashline. “That’s been a real grueling process for physicians because you could document something in a written note, and now we’re saying to document it, but in a discreet data field, so we can capture that information,” she says. “It’s been a real challenge in the physician community—not because they don’t want to—but because it’s a different way of doing documentation.”The Adirondack Medical Home Pilot enlisted the support of the Massachusetts eHealth Collaborative when it was first awarded the $7 million HEAL NY Grant in 2009 to help with EHR selection, implementation, adoption, and meaningful use reporting. "Meaningful use reporting is not a simple, straightforward process—the metrics are open to interpretation, and many of the metrics an organization might chose to report on are not directly supported by the EHRs built-in reporting capabilities," says Dennis Weaver, M.D., HEAL 10 program services director for the Adirondack Medical Home Pilot. "With the Quality Data Center [QDC] we just upload our raw EHR data and they handle all of the aggregation, analytics and reporting, applying the latest reporting best practices as they go. It’s an excellent quality reporting tool for our pilot.”MAeHC has taken a hands-on approach to the pilot, going into physician offices to do workflow evaluations and data remediations, and to streamline documentation to create one standardized location for documentation. “Template development was a huge portion of it,” says Pam Minichiello, R.N., project director and MAeHC lead on the Adirondacks pilot, “where within their individual EHR we develop one place within their documentation template where they can document the key elements that we needed for the reporting.”

Pam Minichiello, R.N.To glean some early results from the pilot, the three pods did an interim dashboard last August targeting a few key measures. However, practices were not consistently storing data in the same places within the EHR, and therefore, data was not able to be compared across the board. “We just started the QDC analysis on the data, and it’s difficult to measure that performance at this early stage because what we’re really measuring right now is the quality of the data we’re receiving rather than the performance of the pod or the individual provider,” says Minichiello. Ashline does say though, that ED utilization data has shown that visits have gone down.MAeHC is also the implementation agent and regional extension center (REC) for New York State to help practices achieve meaningful use. Minichiello says 85 percent of the pilot practices have already attested to Stage 1 meaningful use. “HIXNY has a direct connection into the MAeHC QDC, so we will actually be taking the data directly from the EHRs,” says Minichiello. “It will go into the QDC for processing, and then we will be able to supply the pods and practices with a portal where they can go in and view the measurements across their own pods, practices, and provider to provider.”The Adirondack Medical Home Pilot has eight EHR vendors currently involved in the pilot, which bring its own interfacing challenges. “I think the most important thing would be to have one EHR,” says Moore. “We have [eight] EHRs across our pilot, and trying to get interfaces for [eight] EHRs is exponentially hard.”In the Adirondacks, where sometimes there is only one PCP for more than 25,000 people, sometimes it’s just challenging for physicians to see all their patients in a day, says Ashline. “And then when you add a layer of documentation that’s foreign to them, those are real challenges,” she says. “And then to say, ‘by the way you need to follow-up on all your referrals. They’re just trying to get through the day and make sure they get what they need.”“The biggest challenge quite frankly is having physicians and payers pretend to be on the same side of anything,” Moore says. “We’ve all been on separate sides of the team, so bringing us together to all work toward common goals has been incredibly challenging.”