4 Ways to Improve Care Delivery in the Medical Home

Thursday, November 5th, 2009
This post was written by Melanie Matthews

Michael Erikson, vice president of primary care services for Group Health Cooperative, shares four strategies that dramatically improved care delivery in Group Health’s successful medical home pilot.

Call management was a necessary underpinning of our patient-centered medical home (PCMH). Prior to the work on our medical home pilot program, our delivery system was only about 9 percent capable of taking a call from a patient into our primary care practices and resolving that in the first call. For those patients whose call could not be resolved, it often took hours to days to get their answer to a simple question. Currently, all 26 medical centers can answer that patient’s call 80 percent of the time the first time they call, and no patient waits longer than 45 minutes for an answer to their clinical question. It was also necessary for us to deliver access. We had to continue what we learned in 2005. We couldn’t drop the ball on that. Patients still need to come in for visits. We now have standard work around demand management — providing same day/next day access to patients and we’re being successful on that front.

The second strategy of our PCMH I alluded to in my introductory comment, and that was to proactively use virtual medicine, which is secured messaging on the phone to substantially improve care planning and connection with patients. We now have no less than two standard phone visits per day per physician, every day of the week. Patients can request and book a phone visit with their physician. Physicians can also request that the patient have a phone visit if there are lab results that need to be followed up on that require a direct conversation. We also wanted to use secure messaging for those patients who are activated on MyGroupHealth, which is our Web-enabled interaction with our patients. It’s a secure Web site that is connected to their electronic medical record (EMR). They have a view of their EMR as well as e-mail correspondence to and from the physician, and become a part of that ongoing medical record. It was a way for the physician in the medical group to do much more proactive planning with patients.

Prior to our medical home pilot, virtual medicine was reactive; when patients e-mailed us with questions, we would answer. In our medical home pilot the medical group converted that and began to be proactive. In other words, the patient who would have a visit and start on a new medicine on a Monday or a Tuesday would receive a secured message from their physician two to three days after that visit asking how they were doing on their new medicines. Were they having any side effects? Were there any lingering questions that were not answered in the visit? By having the care teams actively reach out to the patient, it reduced unnecessary calls to the care team and unnecessary visits. It enabled the medical group to move from 20-plus visits a day down to 14 visits a day in our pilot clinic, a strategy that is now moving as we spread across all the delivery system.

The next strategy is chronic disease management (DM). You want a primary care system that is uniquely capable of dealing with many of the chronic illnesses. We have standard work elements for the care team around your five core ambulatory-sensitive care conditions: diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), hypertension and asthma. The care teams have standard processes for working with patients around those chronic illnesses. It is what drove part of the cost neutrality of our medical home pilot in one year that moves to a cost positive or cost reduction in the two-year study.

Next, in order to move primary care forward, the care team should begin preparation for visits well in advance of the patient arriving. With our EMR and its registry-like functions, we know the care gaps of the patients who are coming for a visit; all their HEDIS measures. One to three days before visits occur, the team begins to look for any of those care gaps, so that when a patient arrives for a visit, not only are we responding to their acute need, we’re also responding comprehensively to address any care gaps, whether that be a chronic illness, a preventive need as well as their acute needs.

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