As an example of how the report is used, Hummel says one hotspot report identified a new patient with a history of diabetes, sleep apnea, obesity, and hypertension. Alerted by the hotspot report, the practice reached out to the patient, who had not received care in five years.
Providers worked with him to develop a care plan that included physician appointments every three months, self-management, and lifestyle changes. The patient now attends diabetic support classes, maintains a 1,500 calorie meal plan and is losing weight. And he takes his medications as prescribed.
Hummel notes that "there's really a talent to creating that personal readiness and receptivity in patients to embrace the changes they need to make to be an active participant in their health."
As part of the PCPC, physicians learn how patient outcomes can be driven by underlying behavioral issues. Access is critical in patient engagement, so incorporating e-mail and virtual, online visits with a physician practice is important.
Hummel says it will be another six months—probably the second quarter 2014—before cost trends emerge. For now, based on anecdotal, member-at-a-time evidence, she says the PCPC program is delivering "what we thought it would deliver."