News

May 10, 2010

On the Same Team - Patient Centered Medical Home


Monday, May 10, 2010

On the Same Team

By Amanda Schoenberg
Journal Staff Writer
          When Maricela Canales needs to speak with her family's doctor, she picks up the phone. If Dr. Javier Aceves isn't available, he calls back right away.
        When her 12-year-old daughter, Guadalupe Hitzel Canales, who has cerebral palsy, needs a specialist, Canales doesn't leave Aceves' office at Young Children's Health Center on San Pablo SE in Albuquerque without details about where to go and whom to see. In many cases, the appointment is made for her.
        "They make it easy," she says, in Spanish. "I don't have problems like, where do I go now?"
        The Young Children's Health Center, where Aceves is medical director, is one of a growing number of practices to adopt a patient-centered medical home model, which uses an integrated, team approach to primary care.
        While advocates say the medical home is in its infancy in New Mexico, that may change as providers and legislators push for the model and insurance companies work to pay for it.
        The medical home is being considered at the state and federal levels. The final version of the federal health care reform bill, which passed in March, created the Center for Medicare and Medicaid Innovation, which will study the medical home concept.
        The bill also provides funding for primary care training. The state is short about 400 primary care providers, says Dr. Daniel Derksen, professor of family and community medicine at the University of New Mexico Health Sciences Center, who helped craft some of the bill's language as a senior fellow at the Robert Wood Johnson Foundation Center for Health Policy assigned to Sen. Jeff Bingaman's office.
        In New Mexico, a bill signed by the governor last year required the Human Services Department to develop medical home programs with the state's Medicaid, Children's Health Insurance Program and State Coverage Insurance contractors.
        Rep. Danice Picraux, D-Albuquerque, who sponsored the bill, envisions a medical home as an updated version of her own family doctor, who knew his patients and arranged their care.
        "The real goal for me was better health care so people didn't get lost," she says.
        'Change in culture'
        Aceves started the medical home model at the Young Children's Health Center about six years ago. The model requires work to increase communication in the practice and with specialists, he says.
        "It takes a change in culture," he says.
        The center has six doctors and a nurse practitioner, a part-time child psychiatrist, three social workers and a care coordinator, who organizes medical care for patients. A medical home is particularly important for children with special needs, who have more complex needs and often see several specialists, says Aceves.
        Putting patients at the center of care is key to the model, he says. That means making tough calls when, for example, a family wants to see the same doctor every time instead of a resident.
        "We struggle with that," says Aceves. "But we end up saying, we are going to honor the family."
        In a medical home, patients and families are included in all decisions, Aceves says. As a result, Aceves says he no longer has to carry the entire burden of decisions himself.
        Canales sees Aceves as a "guide" to her family's health care. When Guadalupe Hitzel was 3, she had trouble gaining weight and Aceves suggested a feeding tube. Canales says Aceves told her and her husband, Salvador Canales, "As parents, you have your children day and night. Is it all right with you if we do this? First, he asks for the family's opinion."
        They decided to work on their daughter's weight without it. After trying on their own for nine months, they agreed to the feeding tube, which Canales says worked well for her daughter.
        While other practices have added pieces of the medical home, Dr. Arthur Kaufman, vice president for community health at the UNM Health Sciences Center, says the approach UNM experts helped create at South Valley Family Health Commons adds a broader vision.
        The center, which opened two years ago, brings medical, behavioral, dental, public health and the Special Supplemental Nutrition Program for Women, Infants and Children under one roof. It is one of eight community health centers and one school-based center run by First Choice Community Healthcare in New Mexico.
        Kaufman says the health commons looks at health priorities in and outside the clinic. Social factors, such as a lack of education or access to healthy food, should also be addressed in the medical home, he says.
        First Choice medical director Dr. Saverio Sava says the commons uses a team approach that extends beyond the medical side to what he calls the "warm hand-off." If a WIC client doesn't have a regular primary care doctor, for example, the person would be walked over to the clinic and might see a doctor that day, Sava says.
        "To take care of people properly, you need to change the model of primary care," he says. "You need to do it as a team. You need to do preventive care. You need more resources to do that."
        The team approach was incorporated in the design of the building. On the medical side, doctors and medical assistants sit in open offices called "pods," which facilitate dialogue, says First Choice CEO Bob DeFelice. In addition to daily huddles with medical staff, South Valley clinical supervisor Dr. Santiago R. Macias says staff meet quarterly with community groups related to health care.
        Cost savings
        Medical homes focus on primary care, which advocates say can improve health outcomes.
        In a 2005 review of the impact of primary care in The Milbank Quarterly, researchers reported on studies that showed patients in areas with more primary care doctors had lower mortality rates from stroke and heart disease. Areas with higher ratios of primary care doctors also had lower health care costs than other areas.
        While a medical home has high up-front costs, Kaufman says it saves on urgent care.
        "If you can prevent hospitalizations, that's where the big cost is," he says.
        But adopting the model isn't cheap. Medical homes should have behavioral health staff, diabetes educators and case managers, DeFelice says. Electronic records, a critical part of the model, are also costly, Sava says.
        Changing the current payment system is one of the biggest challenges, Derksen says. Payment shouldn't have to be connected to office visits, Sava says. Instead, time spent on e-mails, phone calls and coordinating care could be reimbursed.
        One solution is for insurance companies to add monthly payments for medical homes, Derksen says. They could also reward providers who improve patient health or reduce hospital visits.
        Some companies are on board. In June 2008, Molina Healthcare of New Mexico began offering incentives to providers who seek accreditation for medical homes, says chief medical officer Dr. Eugene Sun.
        In addition to fee-for-service pay, Sun would like to add payments for medical homes that spend time on case management and show better patient outcomes. If he were "very, very optimistic," that could take three to five years.
        "The alignment is there in concept," he says. "But the devil is in the details. How do we get there from where we are now? I think we'll get there because the state is very open to this."
        Principles of medical home
        The American Academy of Pediatrics coined the term "medical home" in 1967 as a central place to keep medical records. The model found support in 2007 when the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association agreed to principles for the patient-centered medical home:
        • Personal physician: patients have an ongoing relationship with a doctor who oversees care
        • Physician-directed medical practice: doctors lead a team that cares for patients
        • Whole person orientation: physician cares for all health needs, from chronic to end-of-life care or arranges for care with other professionals
        • Coordinated and/or integrated care: needs are coordinated across health systems and in the patient's community
        • Quality and safety: the medical home uses evidence-based practice, values patient participation and measures health outcomes
        • Enhanced access: adds expanded hours, open schedules and communication by e-mail and phone
        • Payment: includes new systems that pay for time coordinating care outside office visits