Bon Secours Advanced Patient-Centered Medical Home Redistributes Care Coordination Workload

Tuesday, March 10th, 2015
This post was written by Cheryl Miller

The provider used to bear the brunt of medical care: preventive and chronic care, medication compliance, triaging new complaints. But that model created a bottleneck and was not sustainable, says Jennifer Seiden, administrative director, population health, and Lu Bowman, population health market program manager, for the Bon Secours Medical Group. With the advanced patient-centered medical home, the care team divides up the labor, creating a more fluid care team redesign, and an ultimately more efficient healthcare model.

Now what we’re working on is the ‘C’ in this equation, the care coordination piece of it, the care team and the duties that are new to the ambulatory healthcare system. Together it equates to the advanced patient-centered medical home (APCMH).

The old way of thinking is that the provider was almost like a target, or the bull’s eye. Everything went to the provider to do: the preventive, the chronic, refilling meds, triaging new complaints, getting tests results called back to patients, adding referrals. It’s a bottleneck. It’s not sustainable and it certainly doesn’t lead to satisfied providers or an effective, efficient care delivery system in the ambulatory setting.

Now we use the care team for the division of labor. Every team member has a responsibility that is delineated in the principles of the patient-centered medical home. We utilize them to the highest level of their training and licensure ability. It requires an intensive training and ongoing support program. We have biweekly meetings with a great deal of education; it truly is almost a medical model of education when you learn about the chronic disease processes.

There’s also a social work component. We’re looking into compiling social resources that are needed for the care team. It’s a big community of nurse navigators, of the care team, and so forth. We have biweekly meetings where upwards of 50 to 60 people come together to do continuing medical and nursing education. All of that helps equip them with the knowledge to flow those interventions out from the provider and help that provider do their job. We try to have as many protocols as we can, where we can, in our state.

This is just more of a fluid care team redesign where it delineates a little bit of each of the roles and responsibilities of that care team and what they do. Certainly their provider still has a pivotal role in this but we are able to ease that load.

Source: Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes

Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes describes how Bon Secours’s 600-provider medical group has primed its providers to employ a broad mix of team-based care, technology and retooled care delivery systems to maximize quality and clinical outcomes and reduce spend associated with its managed patients.

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