Four-Story Medical Home Wired with Telemedicine Outreach

Tuesday, June 2nd, 2009
This post was written by Melanie Matthews

Kathy Scher, program manager for the Center for Clinical Care Design at Henry Ford Health System, describes how her organization designed a four-story medical home and identified patients for telemedicine outreach in this model.

When we designed our medical home model, we conceptually built it with a four-story house in mind. On the first and second floors of our home, we have designed the services for a relatively healthy patient population. The patient profile for level two and level one floors is that they’re healthy, but they may have acute episodic illnesses. These illnesses are treated by nurse practitioners, mid-level physician assistants and clinical pharmacists. But the physician is the coordinator of this care. We also provide them with different ways to reach their clinician team — e-visits, shared medical appointments, shared goal-setting and routine screenings.

On the third and fourth floors of our home, the patient profile is a bit different. We have patients with multiple chronic conditions. Usually one or more of these conditions is dangerously out of control or the patients have shown some evidence that they’re not good self-managers. The team has been expanded on this level of care to include complex case managers, clinical pharmacists to address polypharmacy issues and also palliative care services.

The case managers focus on treating the patients with chronic disease. For our particular model, we have case managers who focus on heart failure, diabetes and depression screenings. They handle the needs of the patients who can’t pay for the medications, who don’t have transportation or who need additional services that will help improve their care. Initially, when we started focusing on heart failure as one of the conditions we wanted to build a program around, we started in cardiology. We had a nurse practitioner heart failure program built in our cardiology clinic and those nurse practitioners had access to telemedicine services. We found that it didn’t work out. We built a program that didn’t meet the needs of the patients and we didn’t get enough referrals. Going back and looking at how we could do this differently was part of our next step.

We wanted to look at the data to identify the appropriate populations — have the physicians that we work with in internal medicine look at all of the patients we identified using the administrative data and use that as the first swipe to try to trim the population. Then, we looked at those patients who had high ER visit rates and high inpatient utilization. The physicians collaborated with us and went through each of their patients to determine who would benefit from the telemedicine outreach. They removed patients that wouldn’t be good for this service; perhaps they had a language barrier, had dementia or were being admitted to a nursing home. The collaboration with our physicians was key to our success in identifying the appropriate population of patients.

We started by explaining the value and benefit of the telemonitoring that the case managers would use as one of their tools to help them manage their population, but the physician endorsement was key.

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