How to Make a Medical Home Deliver

This article appears in the September 2012 issue of HealthLeaders magazine.

Patients would like to think that their providers won't hurt them, that providers are coordinating their care, and, in an environment where patients are paying more out of their own pocket, that providers aren't wasting their money. Those are several factors that are supposed to improve under the medical home philosophy, but there are others that patients care more about—notably, their satisfaction. Economics is one reason hospitals and physician practices often evaluate the medical home somewhat differently. Medical home certification is a designation to be sought for prestige and reimbursement incentives from payers. It's also an advertising slogan. It's a way to achieve uniform clinical standards. But does something get lost in translation? Some leaders think so and are working to ensure that what the patients experience and internalize about their medical home matches what the organization thinks it's delivering.

Gradual transition
Thomas Jefferson University Hospitals in Philadelphia began a transition to the medical home framework in its owned outpatient medicine group about two and a half years ago. Barry Ziring, MD, director of the division of internal medicine at the three-hospital system, has led much of the transition and says the impetus began with a desire to change the way the patient interacts with his or her primary care provider, but was also fueled by the knowledge that many of the highly trained, highly paid employees in its practices (especially physicians), were spending valuable time on patient needs that had little to do with actual clinical care.

"Most patients were seen by a physician for a 15- or 20-minute office visit and it was essentially the physician's primary responsibility to take care of the majority of the patient's needs," says Ziring. "Those needs are medical, but they are also psychosocial and administrative and insurance. A 15-minute visit isn't sufficient to have all those needs addressed—the problem being that the medical needs came almost at the end of the appointment."

In fact, that was only one problem among the dissatisfiers experienced by both patients and providers. Recognition of this dissatisfaction led to fertile ground for planting the seed of change among practitioners. In fact, the overriding goal in the evolution of the medical home, says Ziring, is to have everyone at the physician office functioning at the top of his or her license—that is, that they perform the work they were trained to do, work  that no one else can do better. That's simple to say, but much more complicated to administer, especially in organizations where patients have come to expect the physician to address all their needs, and where practices may not have the expertise or the mix of specialized employees to provide the other services patients expect.

"That means many aspects of the patient's care are provided by people who are not physicians," Ziring says. "We all know that in the current economy, medicine is at best a zero-sum game, so it's not an opportunity to have physicians necessarily spend more time with patients. Instead, we can make use of everyone in a better way so the patient gets more quality time with their physician."

Jefferson has achieved Level 3 status as a patient-centered medical home—the highest designation from the National Committee for Quality Assurance, which certifies medical homes nationally—but the process takes some getting used to, by patients and providers alike.

Patients are finding they're summoned to previsit planning meetings that might involve lab visits so results are ready by the time the physician appointment takes place. Such meetings might also involve a consult with a social worker, a nurse, or nutritionist. And with an electronic medical record populated with the latest results, visits with the physician are more productive and offer fresh data for the doctor to review with the patient. 

"Instead of the patient getting an appointment that's 20 minutes with one person, they might get an hour in sum total with others," Ziring says.

But do the patients like it?
"We're starting to measure that but at the moment, it's not something we keep particular track of," Ziring says. "But the physicians get the sense that there's improvement in patient compliance and satisfaction. And I should say that in practices that have been doing this longer than we have, when they measure physician and staff satisfaction, that improves as well. So happier doctors …"

And the doctors, unquestionably, are happier for the transition, Ziring says. That has also eased the transition to new work protocols, and other members of the care team, such as case managers and nurses, have direct contact with the patient in an advisory role.

"For the most part, we here found it to be relatively easy," says Ziring of the transition. "But that may be in part because we had a group of physicians who really felt overburdened and felt they weren't providing the best possible care they could. It's an evolution and nothing succeeds like success, that is, if patients are happy and docs notice over time that their health improves. We're still implementing some of these changes, so it's a very gradual process."

Quick, big changes
Affinity Medical Group—a team of 250 healthcare professions and an insurance plan that is the physician group subsidiary of Affinity Health System, a three-hospital regional integrated delivery system based in Appleton, Wis.—started making the transition to the medical home philosophy about three years ago too. Its changes have been dramatic.

The effort started with two pilot programs. In one, leadership targeted an existing 400-patient practice that had big promise for patient growth. Interestingly, leaders didn't require existing workers to stay for the big experiment. In fact, employees were required to reapply for their jobs at the clinic.

"In that case, we basically started a new practice," says Tim Loch, senior vice president and chief operating officer at Affinity Medical Group.

Affinity took another existing practice that already had a 1,000-plus patient panel and implemented the medical home transitions there as well. There were big changes, which included keeping close track of metrics such as patient satisfaction, access to specialists, and the length of wait to get appointments. But the biggest changes were in work patterns and programs, says Loch.

Subsequent programs include integrating pharmacists into the clinics for direct consults with physicians and patients, and case managers come to the clinics regularly to help coordinate inpatient and outpatient care. Affinity even has developed a house-call program that not only provides care at home, but serves the additional purpose of assessing the patient's home situation and environment. That's probably where the change in routine is most obvious to the patient, says Loch, but how does he know patients are improving in outcomes and satisfaction?

"We put the care back closer to the patient and the primary care provider," he says. "Everything else has metrics."

And the metrics are impressive, especially in financial terms. Affinity's decision to adopt the medical home was perhaps easier to make than for other providers because its own health plan was involved. Any savings would be guaranteed to return to the overall organization.

"For two pilots the health plan invested $300,000 and got a return in excess of a million. That's proof of concept," says Loch. "Not every practice is like that, but those trends are in place and show medical costs are down and quality and patient satisfaction are up."

But even more impressive have been the cost results. Affinity broke out its outpatient costs into primary care, specialist care, and overall outpatient costs, and while the non–medical home practices' overall costs rose 9.7% over two 12-month periods in 2009–2010, those with medical homes rose only 0.62% during the pilot period. In its component parts, specialist care costs dropped 11.97% among medical home patients while rising 8.51% among non–medical home patients. When including both inpatient and outpatient cost information, the results were even more dramatic. Inpatient costs for patients in the medical home practices dropped 43.66% over the same time period while they fell only 6.38% among non–medical home patients. Overall, costs dropped by 14.22% among medical home patients while they rose 6.6% for non–medical home patients.

With results like that, the pilots are no longer pilots, and all of Affinity's owned practices have adopted the medical home philosophy, and all have received Level 3 designation from NCQA. What was the key to the successful transition from a senior leadership standpoint?

"From senior leadership, you're at the point where you've got to believe in it and you're moving forward," says Loch. "Quit questioning if this is where it's going to go."

Do the patients like it?
Believing in the changes from an executive and clinical point of view is one thing, but the success ultimately rests on whether the patient finds the changes to be an improvement. "We struggle with that because a lot of the work for the patient is done in the background, and it especially comes into play with chronic conditions," says Jane Curran-Meuli, the regional administrator for primary care at Affinity Medical Group. She says that care conferences, behavioral health, and automated outreach through Phytel (a Dallas-based company that provides Affinity a registry that uses evidence-based chronic and preventive care protocols to identify and notify patients due for care) offer multiple opportunities for providers to proactively manage patient care, which improves patient satisfaction and outcomes. "Those who have those conditions certainly see the difference."

Some of the things patients notice include turnaround times for lab results, and how quickly someone at the practice gets back to patients who have called in with a question, says Karla Repta, director of patient care services at Affinity Medical Group.

"The processes have really tightened up those time frames so patient experience is more positive than it was," she says.

Nine out of 10 Affinity patients would recommend the medical home format to their family and friends.

Loch says that measuring the impact on the patient is educated guesswork, and the metrics bear out that patients are generally more satisfied with their care, and costs per patient are going down, so that's good enough for him.

"We evaluate some through our marketing, but we were first out in the market telling people what a medical home is. Everyone's now copying that sell."

Affinity also recently hired a "connection specialist" to make the medical home case directly with employers. "She's talking about how things work, how we connect those with chronic conditions, and she's extolling the virtues of medical home. She's only been here two months, but it seems to be catching on."

One local employer has evaluated all local primary care providers on a 100-point checklist, says Loch, and "they're actually paying the employees and us more to take new patients because they want their employees to come to our clinics."

Reprint HLR0912-5

This article appears in the September 2012 issue of HealthLeaders magazine.