Building a Successful Medical Home

In the great debate over healthcare reform on Capitol Hill, one issue that intrigues legislators is the idea of a patient-centered medical home. With this model, patients would get to spend more time with a primary care provider—receiving more personalized care that could emphasize prevention and more patient involvement in medical decision-making.

New models are being tried out across the country, but one organization—Seattle-based Group Health Cooperative—recently revealed what the costs and benefits are to implement this model through a one-year pilot project at its Factoria Medical Center in Bellevue, WA. Based on the final results, GHC will be rolling out the model at its 26 other medical centers in Washington and Idaho beginning in 2010.

"We picked a clinic where we could pretty assuredly make the changes that we wanted to make and then observe to see what happened," said Robert Reid, MD, an investigator with the Group Health Research Institute. "The practice had good leadership . . . and it had a prior history of real successful practice change so that we knew the clinic could transform in a way we envisioned."

In the long term, "substantial transformation" was needed to make the switch to a successful medical home, Reid said. At the top of the list was reducing the number of patients in each primary care physician's panel from about 2,400 to 1,800. Reducing the number of patients would leave more time for coordination, outreach, and office visits, which were extended from 20 to 30 minutes per patient).

But on the flip side, that has meant more costs—or about $16 more per patient per year in those costs related to hiring more primary care providers plus other staff for the primary care team: 15% more for primary physicians, 72% more for clinical pharmacists, 44% more for physician assistants, 18% more for medical assistants, and 17% more for registered nurses. Overall, patients at the medical home used $37 more in specialty care—possibly because the enhanced primary care services detected previously hidden health problems.

However, on the flip side, because of fewer trips to the hospital emergency department (down by 29%) and fewer hospitalizations for conditions that primary care can prevent (down 11%), costs were reduced by $54 for each patient in the pilot clinic, which essentially "paid" for the staffing changes. More details are provided in this month's issue of the American Journal of Managed Care.

The clinic also emphasized use of both e mail and telephone encounters—as an alternative or complement to in person visits. This resulted in a 94% increase in e mail use, a 12% rise in more phone consultations—and 6% fewer in person visits.

For the patient experience, those in the pilot reported higher ratings than controls on six out of seven patient experience scales. For staff burnout, 10% of pilot's staff reported high emotional exhaustion at 12 months—compared with 30% of controls, despite similar rates at baseline.

So can this model work around the country? Reid noted that GHC is different than many organizations—for instance, its physicians are salaried. However, to make a model successful, it became apparent that the organization needed money up front to give its providers "breathing" room—time to meet with patients and generally open up time in their day.

"I think it's important to realize that there has to be investment up front," Reid said. But the payout—in terms of less hospitalizations and emergency visits—and even happier patients and providers—may work out in the end.