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The Medical Home Meets Telehealth at Eden Health

Analysis  |  By Scott Mace  
   October 29, 2020

Continuity of care meets the telehealth needs of employees and their employers.

The patient-centered medical home, combined with telehealth, is not a typical combination.

But one provider organization is covering 30,000 lives and has served more than 100,000 visits in 2020, this year of the pandemic, through such an offering.

Offered through employers and also real estate building landlords, Eden Health combines telehealth with medical home methods to enable the process of family members seeing the same primary care specialist over time, improving continuity of care and reducing costs in the process.

The four-year-old, NCQA-certified medical home operated by Eden Health, serves a variety of employers, including Emigrant Bank, Stack Overflow, and Golf. During the seven months of the COVID-19 pandemic, Eden Health's business has grown sevenfold, according to CEO Matt McCambridge.

“What we've built is really a concierge doctor for every person," McCambridge says. "It's coordination of care that's integrated with the medical delivery of care with clinicians, care navigators, behavioral health providers, and physical therapists in a patient-centered medical home format."

With five brick-and-mortar clinic locations in New York and New Jersey, as well as staff visits to employer sites, New York–based, U.S.-focused Eden Health complements telehealth available in all 50 states with in-person physicals, screenings, vaccinations, lab work, and physical therapy as needed.

A changed visit mix

The pandemic changed its visit mix. Before it, Eden Health patients did two-thirds of their visits virtually. Now, virtual visits comprise 99% of all visits. McCambridge contends that the medical home aspect of its practice distinguishes it from almost all other telemedicine providers. As a general rule, those providers do not permit patients to see the same primary care physician each time, building up a continuity of care, but instead typically provide a different physician for each episode of care.

When asked if Eden Health patient outcomes exceed those of traditional telehealth or brick-and-mortar systems, McCambridge replies that the company tracks all the outcome data that any NCQA-accredited medical home tracks, such as the Generalized Anxiety Disorder Assessment (GAD-7) and the Patient Health Questionnaire (PHQ-9) depression module, as well as HEDIS metrics. "We're really proud that we have a collaborative care model on the behavioral health side," he says. "About 96% of our patients who are diagnosed with depression actually receive treatment for that."

Pictured: Matt McCambridge, CEO of Eden Health. Photo courtesy of Eden Health

As a value-based care provider, Eden Health pays its physicians a salary, and the usual fee-for-service incentives to generate billable hours and referrals are not present. "The average primary care physician out there is referring patients to a specialist 33% of the time," McCambridge says. "On our end, we refer 10% of the time to a specialist, so we significantly decrease the rate at which specialist refers happen, and do a lot more care at the primary care level, by spending more time with the patient."

When referrals do occur, Eden Health's primary care physicians take care to make them as accurate as possible. "We are going to do the lab work and the image work that's going to be required ahead of time," McCambridge says. "When they enter the specialist's office, that specialist is going to know it's a pretty high probability that that person is going to need that kind of care, rather than having 40% of their day spent telling people, 'I'm not the right specialist for you.' "

Following specialist visits, Eden Health follows up with patients to make certain that the patient understands the care plan. "It ends up with patients being more compliant, and specialists can know they're handing patients off to somebody who will manage their care plan over time," McCambridge says.

Employers are driving this vision of care in response to the continuing spiraling costs of fee-for-service care. "Typically, there's not much leverage for the employer to do a whole lot," McCambridge says. "You have to be quite big, and I'm not sure there's really much economic incentive for the hospital systems to do something differently."

McCambridge started Eden Health after having been dismayed to see his sister endure a series of post-ER incomplete or incorrectly diagnosed medical ailments, as more than 70 specialists failed to coordinate her care. "Luckily, about four years in, there was a primary care provider who was able to bring the pieces together with a few specialists, get her the right care, and allow her to grow out of the condition."

Such poorly coordinated specialist care can also lead to unnecessary surgeries that not only endanger patients, but also further inflate already-inflating healthcare costs.

Among all Eden Health patients, 60% have Eden Health as their primary care provider of record, and 40% use Eden Health in some supplementary capacity. This could be for various reasons, such as not having their regular primary care provider available at 2 a.m., or their traditional provider's inability to guide patients through specialty care, McCambridge says.

Telehealth services, even those covered by employers, traditionally have had difficulties getting adoption beyond single-digit percentages of employee populations. McCambridge contends that marrying telehealth with the medical home model achieves the kind of adoption of telehealth that episodic telehealth providers still dream of, and providing medical home services in the bargain helps employers get the kind of engagement that often eludes traditional healthcare systems. "It's not an afterthought, or maybe something that's not the real focus of the [traditional] healthcare institution that's providing care," he says.

“The average primary care physician [refers] patients to a specialist 33% of the time; we refer 10% of the time.”

Scott Mace is a contributing writer for HealthLeaders.


Four-year old Eden Health already covers 30,000 lives in the NY–New Jersey region, and it saw a surge of telehealth usage during this year's pandemic.

Its national footprint attracts employers concerned about high costs of traditional healthcare, and the disconnected nature of traditional referrals.

Among all Eden Health patients, 60% have Eden Health as their primary care provider of record.

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