Problem Addressed

• Poorly coordinated care: Most primary care practices lack the staff and technology to effectively coordinate patient care. The problem is especially severe in military and other government-run clinics, which seldom provide care coordination and management activities and, in some cases, preventive care to veterans and active duty personnel with chronic health conditions.¹
• Lack of information technology: Military and civilian health care facilities often do not have information systems that can improve communication between patients and providers, between primary care providers and specialists, and across care sites. When such systems are available, clinicians do not always use them.
• Failure to integrate behavioral health: Integrating a behavioral health specialist, such as a psychotherapist, into civilian or military primary care settings can improve patient and provider satisfaction, reduce symptoms, improve patient functioning, and lower health care costs.² Patients are also more likely to make an appointment with an onsite behavioral health specialist than with one located elsewhere.³ Despite these potential benefits, few civilian or military primary health centers offer onsite behavioral health services.
• Unrealized potential of medical homes: Providing patient-centered, coordinated care reduces the need for costly emergency department (ED) visits and hospitalizations. Denmark organizes its entire health care system around patient-centered medical homes that promote care coordination, which has contributed to its having the lowest per capita health expenditures among all Western developed countries.⁴ However, few military or civilian primary care clinics in the United States follow this model.

Description of the Innovative Activity

The National Naval Medical Center created integrated medical home teams within its internal medicine outpatient clinics to provide personalized, proactive, coordinated care and care management to patients. The teams provide care, make appointments with specialists, follow up with patients as needed, and integrate behavioral health specialists at the point of care when appropriate. A robust online medical portal and personal health record system support the care process, allowing patients to add information to their medical records and communicate via e-mail with team members, who, in turn, use the systems to identify patients who need followup care and to conduct virtual office visits. Highlights of the medical home model follow:

• Team make-up and caseload: Each medical home team serves about 3,000 patients. The team consists of two internal medicine physicians, a physician assistant, a registered nurse who typically serves as the care manager, three licensed practical nurses, and two or more administrative assistants. All members are housed in one team office to improve collaboration, communication, and accountability. As discussed further below, behavior health consultants (including psychologists, and licensed clinical social workers), dietitians, and mind–body medicine therapists are available onsite, with each specialist serving up to 6,000 patients.
• Comprehensive, personalized, proactive care and care management: Each team provides comprehensive care based on individual patient needs, referring patients to military or civilian specialists as needed for preventive, acute, and chronic illness care that cannot be provided onsite. A team member makes any needed specialist appointments before a patient leaves the clinic and then contacts the patient by e-mail or phone to provide test results or other followup information related to the visit. Previously, the patient was responsible for making these appointments and obtaining this information.
• Open scheduling, virtual visits, e-mail/phone communications: To make access to care as easy as possible, the clinic offers open scheduling that allows for same-day appointments for acute care and appointments within 3 days for routine care. In addition, patients are encouraged to call or e-mail providers with questions or prescription refill requests; someone always answers the phone (rather than forcing patients to leave a message, as occurred previously), and providers call patients back to answer their questions in a timely manner. Patients are also encouraged to schedule "virtual" (rather than face-to-face) visits with providers when appropriate. (See next bullet for more information.)
• Non-traditional services within primary care setting: To allow patients easier access to additional services, the program provides the following specialists to patients within the primary care practice. For most of these services, the patient can meet with the specialists immediately after their primary care doctor’s visit or schedule a followup visit.
  • Behavioral health consultants (psychologists): These specialists offer 30-minute appointments with patients to assist in coping with various medical conditions, changing lifestyle habits, helping with family or relationship difficulties, managing stress, and/or dealing with bereavement, depression, anxiety, or anger problems.
  • Diabetic educators: These specialists provide patients with a new or established diagnosis of diabetes with comprehensive medical management and education. Patients can schedule an appointment for educational classes or individual case management
  • Dietitians: Dietitians offer individualized nutrition education and counseling for patients with chronic diseases, such as obesity, diabetes, heart disease, and hypertension.
  • Mind–body medicine therapists: These therapists offer educational/experiential sessions (either individual or group) and classes to patients to help reduce stress. They focus on teaching patients self-care skills, such as meditation, yoga, guided imagery, expressive arts, and mindful living skills.
  • Clinical pharmacists: These pharmacists perform comprehensive medication counseling and review, medication reconciliation, and screening for drug-related problems.
  • Health educators: These educators provide education on specialized topics, such as tobacco cessation, stress management, decisionmaking, anger management, and sexual health. These services are available through individual appointments, group support sessions, online programs, and/or shared medical appointments.
• Web-based personal health records and systems to support care management: A Web-based portal allows patients and providers to better manage care.
  • Patient-input information via Web site: Through a secure Web site, patients can register, provide information and answer questions about their health, and check in before an office visit. Patients are also encouraged to enter clinical information, such as recent blood glucose or blood pressure readings that may be helpful to providers. Patients can use the system to communicate with providers and health care teams and/or to schedule a "virtual" office visit with a team member, with the software providing templates and other information to enable the virtual visits and previsit screening. Patients can also use the system to rank their satisfaction with providers. Online enrollment began in May 2009, and, within 2 months, about 15 percent of patients had registered. Team members hope to ultimately enroll about 70 percent of patients in the online system.
  • Electronic kiosk: This kiosk allows patients to sign in for appointments by swiping their identification card (rather than waiting at the front desk to speak to a clerk), validate and update demographic information, receive alerts about overdue tests or immunizations, and answer clinical questions before seeing their primary care provider. Data entered into the kiosk flows into the electronic medical record, thus providing doctors with immediate alerts when patient-entered information creates the need for intervention during the visit, and also allowing for immediate feedback on patient’s mental and physical well being during the visit.
  • Provider support through alerts and performance feedback: The system provides physicians and team members with a wealth of data on patients to help providers better manage care, with secure access available from outside the office. For example, the system flags patient records and sends out alerts when patients have not been seen or screened as recommended by best practices, and provides disease management tools to improve care for patients with chronic illnesses. The system also provides individual physicians and teams with comparative performance information on several HEDIS® (Healthcare Effectiveness Data and Information Set) measures (e.g., blood glucose for those with diabetes, breast cancer screening), productivity, and patient satisfaction. The system also promotes colleague-to-colleague correspondence to facilitate sharing of best practices.
  • Facilitating followup care for patients seen in ED or hospital: The system alerts the team when a patient has been treated by the ED or hospitalized in the past 24 hours. This communication enables the team to arrange appropriate followup care.
• Ongoing patient oversight: An advisory council made up of medical home patients regularly evaluates clinic care processes, voicing any concerns and making recommendations to improve care.

References/Related Articles

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Results

One year after initial implementation, the medical home team program had improved screening rates related to diabetes and breast cancer and enhanced provider continuity, access to care, and patient–provider communication.

• Improved screening rates: The percentage of women age 52 to 69 who had one or more mammograms in the previous 24 months increased from 74 to 90 percent. The percentage of patients with diabetes who had blood glucose screenings in the previous 3 months and low-density lipoprotein testing in the past year rose from 50 percent to more than 90 percent.
• Enhanced provider continuity: The percentage of visits during which patients see their regular primary care manager/provider (rather than an unfamiliar provider) rose from 55 percent to nearly 90 percent. After the launch of two additional teams in January 2009, this rate rose from 63 to 78 percent for one team and from 48 to 70 percent for the other.
• Enhanced access to care and patient–provider communication: As noted, medical home patients receive same-day access for acute care and can see a provider within 3 days for routine or preventive care. By contrast, patients not enrolled in medical home clinics wait an average of 3 days to see a doctor for acute care and 7 days for routine care. In addition, virtual visits and e-mail communications between providers and patients have increased fourfold since program implementation, with no decline in face-to-face visits.
• Future evaluation of impact on ED and hospital use: In the future, the information technology (IT) system will be used to evaluate the effectiveness of the model in preventing hospitalizations and ED visits.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps included the following:

• Choosing staff for pilot: Department heads handpicked staff for the first team 9 months before launch of the medical home clinic. Recognizing that the structure and culture would dramatically change, they chose staff based on their flexibility and willingness to participate in a new model.
• Conducting team-building exercises: Numerous team-building exercises were held to create a collaborative team.
• Refining model and care processes: The team refined the medical home model and patient flow processes to meet the needs of the patient population, including determining how behavioral health and referrals would be integrated into patient care and how care coordination activities would be managed.
• Creating physical infrastructure: Program leaders designated a common office for the entire team, with the goal of promoting teamwide communication They also decided to redesign the clinic's waiting area to resemble a comfortable lounge.
• Creating IT: During the team-building process, program developers worked with IT specialists to create the portal and electronic personal health record system, using technology from RelayHealth to support the patient flow process. IT specialists also designed a medical home management system for clinicians that included population management functions, indepth data search capabilities, and point-of-care content support based on evidence-based medicine. Team members received training on all of these systems. Staff copied and pasted patient records into the system once it had been developed.
• Introducing patients to model: All enrollees in the pilot program (approximately 1,200 patients) received a letter explaining the new medical home model and inviting them to a town hall meeting to learn more about it. The team held two meetings per month over a period of 10 months, with roughly 5 percent of enrollees attending. Program developers also engaged in other activities to promote education about the model within the patient community.
• Program expansion: Two years after the first pilot team was launched, the medical center expanded the program. At present, eight teams serve roughly 24,000 patients. Medical center leaders plan to create additional medical home clinics to serve children, adolescents, wounded soldiers, and geriatric patients.

Resources Used and Skills Needed

• Staffing: Initially, the program required no new permanent staff, as existing staff were retrained to work in the medical home clinic structure. Registered nurses, who perform much of the care coordination work, are critical to the program's success. To ensure successful team-building, coaches and consultants promoted collaboration and commitment to the new patient care model.
• Costs: Data on the cost of implementing the model, including development of the supporting IT systems, are not available.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Empower stakeholders to develop program: Because implementing the model represents a major cultural change, clinic or practice leaders must be empowered to reassign staff and mandate changes in job assignments.
• Choose and refine a medical home model: Several medical home models are under development by government and private sector organizations. Choose a model that can effectively serve the practice's population, taking into consideration age, demographics, computer usage and access, and chronic disease management needs. The model can be redesigned to conform to patient needs, and the care team may be expanded to include behavioral health and other specialists as needed.
• Identify IT needs: Several commercial IT products can support the medical home model. Select systems that "talk" to each other and best serve patient needs.
• Invest in team building: Set aside an appropriate number of weeks for training and team-building exercises. If effective team building does not occur, the staff will struggle to work collaboratively.

Sustaining This Innovation

• Be prepared to innovate: Periodically reexamine the model's strengths and weaknesses, making changes as needed to ensure it remains patient centered and achieves its goals.
• Improve integration of disparate information systems: Navy officials eventually hope to create a comprehensive information management system that will allow teams to access what are currently disparate medical and patient health records through the portal. The ultimate goal is to provide evidence-based resources at the point of care, a patient-centered education portal, and assistance with check-in procedures for patients.
• Continue team-building and coaching efforts as program expands: After launching the second medical home team, the clinic cut back on coaching and team-building efforts due to time constraints. The team's performance suffered as a result, and, ultimately program developers decided to provide the same team-building exercises given to the first team.

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