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Dr. Gregg Rockower, Clarkston Pediatrics
Dr. Gregg Rockower says the transition to a medical home was relatively easy because his practice had already implemented an EHR system.

Primary care with a personal touch

Medical Homes Survey reveals diverse settings, but single goal: Increase quality of care


By Andis Robeznieks
Posted: October 20, 2012 - 12:01 am ET
Tags:

When primary-care physicians needed to go somewhere new to revitalize their field, they found that there was no place quite like the patient-centered medical home: A practice model that emphasizes care coordination, increased access and enhanced doctor-patient communication—all with an emphasis on continuous quality improvement.

Modern Healthcare's second annual Medical Homes Survey, conducted June 25-Sept. 28, drew responses from 29 organizations. The survey sample illustrates the wide variety of settings among the 4,870 sites that have been recognized as medical homes. One survey response came from an organization with a staff of 350 doctors, and another came from a solo practice. The largest group in the survey has an enrolled patient population of 939,000 while the smallest has 823. One thing they have in common is a desire to increase the quality of care by advancing an old-fashioned concept that is often enhanced by the newest technology.

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While it's not mandatory that medical homes be led by a primary-care physician, Dr. Roland Goertz, in a speech marking the end of his six-year tenure on the American Academy of Family Physicians board of directors, took note of how medical homes are changing the primary-care landscape.

“There has been no single thing that has created more positive energy for family medicine in my years of involvement in policy with the organization, which dates back to the early 1990s,” Goertz, a former AAFP president and past board chairman, said last week at the group's annual Congress of Delegates meeting in Denver. “I have little doubt that, without its construct, we would not be in the policy offices in which we are and would not be having the successes we are having improving the position of family physicians and the needs of our patients.”

Developed in February 2007 by the AAFP, along with the American Academy of Pediatrics, American College of Physicians and the American Osteopathic Association, medical-home principles call for adopting a “whole person orientation” toward patients while providing them with increased access (in person and via secure electronic communication), coordinated care and a focus on continued quality and safety improvement facilitated by health information technology.

The transformation to a medical home can be difficult for some practices. It usually involves the implementation of an electronic health-record system, creation of computerized patient directories that help track the care of patients with chronic conditions and reorganization of staff for more convenient access to care.

Sometimes patients can get confused by the changes.

Between June 2006 and May 2008, the AAFP conducted its national demonstration project that included 18 self-directed practices and 18 that received help from TransforMED, the AAFP's medical home-transformation consulting service. Dr. Terry McGeeney, president and CEO of TransforMED, noted at the time that patients were noticing the “turmoil of change” and how some patients—perhaps shocked by the sudden availability of their doctors—figured their availability was a sign the practice was in trouble and being abandoned by patients.

Dr. Ramona Seidel, owner of Bay Crossing Family Medicine in Arnold, Md., was the only solo-practice doctor to participate in the Modern Healthcare survey. Besides herself, Seidel has only one full-time person on staff to handle administrative duties, and she says patients were taken aback to get calls from the nursing student she recently hired part time to help with care coordination.

The response from some patients was, “Who's she?” she recalls.

Seidel opened her practice in 2005, before the principles of a medical home had clearly been delineated, but she says the operation was based on the AAFP's 2004 report, The Future of Family Medicine, which outlined many of the same ideas.

Medical Homes patient volume
“I opened with the intent of following these tenets,” she says. “So I didn't 'transform,' because—when I opened—I decided I would open with electronic health records, longer patient visits and more patient tracking.”

Seidel adds that she is participating in a CareFirst Blue Cross and Blue Shield medical-home pilot that is paying her a per-member, per-month management fee, between $2.45 and $3.10 a month, but the program includes only patients covered by the local plan. Seidel has several patients covered under a federal Blues plan and she doesn't receive a care-management fee for them, so “there's not a big whirlwind of cash coming through the door,” she says.

Seidel acknowledges that she's out to prove a point. The medical-home concept is often promoted as “team-based care,” which is not the case with her small practice of 1,700 patients.

“It's a fallacy,” she says, adding that it's also “driving a wedge between small practices that want to stay independent” and the rest of the primary-care field trumpeting team-based care.

It is tough to go it alone, but Seidel insists it can be done.

“It's a lot of work, but it's a lot of work to be a doctor anyway,” she says.

On the opposite side of the spectrum from Seidel's Bay Crossing medical home is Dallas safety net provider Parkland Health and Hospital System's Community Oriented Primary Care program, essentially a medical home with 77 doctors providing coordinated care for more than 364,000 patients.

Sue Pickens, Parkland's director for population medicine, notes that the medical home program operates out of 11 locations, so it goes far beyond the walls of Parkland Hospital.

“We're based in the community, so we are the neighborhood doctors' office,” she says.

Dr. Noel Santini, medical director of the COPC program, says the medical home model has increased the productivity within Parkland's primary-care operations with a team-based approach that includes physicians, nurse practitioners, case managers, clinical pharmacists, dietitians, patient educators and social workers.

Communication has been enhanced as well with “virtual encounters,” which are patient visits conducted over the phone or electronically.

“High-risk patients have even more access because they've been assigned a case manager,” says Sobha Fuller, director of nursing for the COPC program.

Dr. Gregg Rockower with Clarkstown Pediatrics, a nine-physician practice with more than 59,000 patients in Nanuet, N.Y., says patients appreciate the speed of electronic prescribing, the ability to ask basic questions with their doctors and refill prescriptions electronically, and the practice's commitment to helping older patients transition from pediatric- to adult-care providers.

“One of the things patients say is, 'My friend's pediatrician doesn't do anything like that,' ” Rockower says, adding that the transition to a medical home in January 2010 was relatively easy because the practice had already implemented an EHR system and was also open longer hours and on weekends.

He adds that the practice has started a lecture series with a local nutritionist to get patients on track in terms of diet and learning the long-term impact of their lifestyle choices.

Rockower acknowledges that getting consensus on an EHR system was a little difficult for a practice of Clarkstown's size and with a partner age range of “just under 40 to just over 70.”

“It's easier to get a consensus with three doctors,” Rockower says. “And when you have a large group of 50 or more, you don't need a consensus. You pick someone who says, 'This is the consensus.' ”

Rockower says he was the one who “bullied his partners into going this way,” but adds that, in order to become a medical home, a practice needs one or two people willing to put in extra work to make it happen and that consensus needs to be built with clinical and nonclinical staff.

When consensus was near, Rockower says he put together a return on investment analysis that got everyone on board.

“I even got the old guys to agree this was the way to go,” he recalls. “Once I got the go ahead, I didn't stop pushing.”


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