Medical Home's Payoff Comes From Effort and Technology

On occasion, medicine resembles the game of golf, and not just because some doctors like to hit the course on Wednesdays. For instance, the secret of a successful patient-centered medical home may boil down to this: a lot of hard work and a few technology tricks.

That's essentially the case at The Johns Hopkins Community Physicians, a division of Johns Hopkins Medicine. JHCP has 35 practices in 11 of Maryland's 23 counties and throughout Baltimore City. The entity consists of more than 400 providers with more than 800,000 encounters annually.

"That was our proof of concept," says Steven J. Kravet, MD, MBA, FACP, president of JHCP. The three goals of the initiative are closely aligned with the objectives of healthcare reform:

1. Improve health in measurable ways.
2. Improve care through improved patient experience.
3. Reduce cost by reducing unneeded and over-utilized acute care.

Improved management of patients with chronic disease states has been an early success of the JHCP efforts. "New patients with a diagnosis of diabetes had a baseline hemoglobin A1C of 8.65," Kravet says. "After they had attended an educational class, their hemoglobin A1C came down to 6.56, and their most recent measure of 6.80 suggests that the improvement was sustained several months later.

Patients who the practices failed to recruit into the classes had essentially no change in hemoglobin A1C. "It's suggesting the power of patient engagement and improvement with group visits and education."

Achieving cost reductions
Reducing the healthcare cost medical loss ratio was another achievement of the pilot at Water's Edge. This figure declined from 86 percent in fiscal year 2010 to 83 percent in fiscal year 2011, and is estimated to drop to 78 percent in fiscal year 2012.

Now that clinical outcomes and cost reduction have been demonstrated, JHCP is turning its attention to issues of staff teamwork, job satisfaction, working conditions and perceptions of senior management. "Those measurements have all gotten worse over the past few years," Kravet says. "We've made the place busier. We haven't paid as much attention to the experience, which has now become our focus."

A key way forward is to customize the technology to meet the needs of managing populations. For example, JHCP has created and is refining preventative care templates for its electronic medical records system. "It forces providers and ancillary staff to ask certain questions and document certain things, so we identify if a patient hasn't had certain types of care or is falling below the standard. All that takes time to develop," Kravet says.

During my recent HealthLeaders webcast on the patient-centered medical home, Kravet revealed a few other tech-related secrets of Hopkins' success. "We used a tool called Conversation Maps that we actually learned from Merck," Kravet says.

A better patient experience
"So one of the key principles of the medical home is changing the approach to care, which is historically very transactional," he says. "In the old model, which is really the current model, people come to see the doctor. They have stuff done to them. Maybe some medications are changed, then they're sent away and they come back in 3 or 4 months or 6 months and they get readjusted.

"But there's a lot of white space between the visits, and that becomes very important in the patient-centered medical home. We began to focus on this big white space, which is really a golden opportunity. We employed care coordination processes, including this perihospital consultation and communication."

Robust tech-powered tracking mechanisms keep tabs on everything from referrals to scheduled tests, and in collaboration with Hopkins' payer arm, Kravet's team assesses risks for each patient. "The highest-risk folks got an RN case manager, and the medium-risk folks got health coaches."

Over the past three years, Kravet says, those clinics where patient-centered medical home practices have been implemented have seen a decrease in emergency room visits, admissions, and readmissions have significantly decreased, and because of this, costs to the related Hopkins payers have declined significantly.

Using Microsoft's Sharepoint, JHCP shares a dashboard that lets all providers, on a secured link, see metrics on quality, workflow, and productivity, and see how they compare to their colleagues. "Once we began sharing this information transparently, we obviously began to see a transformation in our outcomes," Kravet says. "I think that's just because of the inherent competitive spirits of providers, who are all trying to do the right thing."

Overlaid on top of JHCP's electronic medical record are registries, views of data by provider or group that can manage populations. "Again, it's a big part of how we are able to help drive success, because our chiefs and our regional directors can work with practices that are lagging, and help them brainstorm on how to improve their processes," Kravet says.

A large banner hangs in Water's Edge, inhabiting nearly an entire wall. "What good choices can you make today that will affect your health tomorrow?" it asks patients.

Clearly, what Kravet's team has already accomplished has begun generating the shared savings that can fund even more effective patient engagement. His efforts represent the kind of virtuous cycle that healthcare needs to get out of its fee-for-service sand trap.