Can the Medical Home Survive Long-Term?

In Maine, Penobscot Community Health Care is one of them. In 2009, three of Penobscot’s offices were chosen to participate in the Maine patient-centered medical home pilot project, though they decided to roll it out in all four offices. Here’s how they are approaching this task and where they are finding successes and challenges.

Robert Allen, MD, executive medical director at Penobscot, explains that the first step they took was to hire four nurse care managers. Using data from its EMR, the team identified patients who were struggling with specific conditions, such as diabetes. The team also approached physicians to ask for their insights on who could benefit from the program—a key component, Allen says, for buy-in.

“Whether the patient has been in the ER, admitted to the hospital in the last six months, or if the primary care physician just felt they could benefit from the care manager because they were a frequent visitor or had a lot of questions, those where the people we looked at,” says Allen.

Once they started gathering data and speaking with patients, they realized that four care managers weren’t enough to handle the number of patients who needed outreach. So they hired four health coaches and a medical assistant to help with panel management.

“Right now that’s all funded through grants. But as we continue with this, one of our major concerns has been, the more we do this, the more we like it, and we’re worried about the financial sustainability of this long-term,” says Allen. “We hope there will be a change in how medicine reimburses because of all the pilots that are doing patient-centered medical home, and that they [payers] will save a huge amount with it.”