Medical home concept gains ground in Ozarks

Springfield health systems are giving a foothold to patient-centered medical homes, a primary care concept that factors into U.S. health reform, with the end goal of using the concept at clinics throughout the region.

On Feb. 23, CoxHealth’s Family Medical Care Center, 1423 N. Jefferson Ave., a teaching clinic at Cox North with 24 residents and 10 faculty physicians, achieved Level III Physician Practice Connections-Patient-Centered Medical Home status from the National Committee for Quality Assurance. Level III is the highest recognition available, and the Springfield clinic was the second of three Missouri clinics to achieve it, said Apoorva Stull, NCQA communications manager. Stull said the state’s other PPC-PCMH clinics are in St. Louis and Kansas City, part of a nationwide total of about 520.

At the crux of the patient-centered medical home model are the goals of improved efficiency, outcomes and quality.

The shift in health care delivery is significant in the Ozarks, where health care leads the local economy, with a $4.5 billion impact, according to a 2006 study by St. Louis-based Development Strategies Inc.

While CoxHealth has southwest Missouri’s only NCQA-recognized medical home, St. John’s Health System and Ozarks Community Hospital also are putting the concept to work.

Medical homes defined
A medical home is a delivery system that integrates the point of care for patients, said Dr. Tim Fursa, chairman of the committee that organized the CoxHealth clinic’s application about a year ago. The application process cost about $2,800.

“It will integrate primary care of day-to-day needs along with (patients’) special needs, so that all their information comes together (for) a reduction of redundancy, a reduction of waste and just overall better quality of care,” Fursa said.

Dr. Samuel A. Crow II, a St. John’s physician and medical director of the Center for Innovative Care, a Sisters of Mercy initiative, said the concept of the medical home dates back to 1967 with the American Academy of Pediatrics.

“The medical home is a process. It‘s not a place,” Crow said. “There are various touch points, and most of them will be built around primary-type practices and an effort to maximize our specialists in the most efficient fashion, as opposed to sending everybody out of the primary care office.”

Crow said Mercy pilot sites for the medical home concept are in St. Louis and Rogers, Ark., and two area clinics,  St. John’s Clinic-Smith-Glynn-Callaway Family Medicine in Springfield and St. John’s Clinic-Ozark, are set to start piloting the concept this month.

“They’re not so much pilots as they are learning laboratories, because the medical home is being tried, and successfully so, all over the United States,” Crow said. “This is simply taking the current state of medicine to the state that it should be, and that is to the state of health and wellness and to treat chronic disease in a more effective fashion.”

For St. John’s, Crow said, the end goal is to have all of Mercy’s primary care sites using the patient-centered medical home model, though he said that’s probably 10 to 15 years from fruition.

Changes for the better
The patient-centered medical home focuses on elements such as access, communication, patient registries and tracking laboratory data, said Dr. Larry Halverson, senior faculty physician with CoxHealth’s Family Practice Residency Program at Family Medical Care Center. FMCC scored 80.25 points out of a possible 100 to achieve Level III status.

Key components of care coordination are electronic medical sharing, as well as taking a hard look at three chronic conditions prevalent in a practice, he said, particularly in terms of treatment and outcomes.

For FMCC, the three conditions are diabetes, depression and chronic pain, and the doctors use intermediate indicators – blood sugar, response to therapy and pain levels – to assess patients.

“We look at these three chronic conditions with detailed reports of how the patients are doing: better, worse, average or the same. Doctors have done that forever, but never tracked it on a practicewide basis,” Halverson said. “Now I can (determine): Is my whole practice getting better? And that’s a big change.”

While Fursa and Halverson said FMCC could likely have qualified for Level I medical home status without making any changes, their main goals in pursuing the highest level was to improve care and clinic operations, and serve as an example to other clinics that might want to use the concept.

Some changes are small, and though it’s too early to gauge specifics, they stand to make big differences. For Halverson, one such change is the switch from verbal to written patient instructions at the end of each visit.

Fursa said efficiency is central to the medical home process, and FMCC has altered its appointment policy to allow walk-in patients.

“We were scared at first, thinking maybe there was going to be too many, but as it turns out, there’s just the right amount, (and) it helps develop that relationship between the patient and the clinic,” Fursa said.

Another key element of the medical home concept is payment reform, which Fursa and Crow said is facilitated through a three-part plan under the medical home process. First, there’s a fee-for-service for the visit, but the medical home model also has monetary incentives for quality and results – and a big change is that it reimburses the primary care physicians for the legwork they do when further tests or specialized care is necessary.

Springfield-based Ozarks Community Hospital has used medical home principles for several years, said CEO Paul Taylor, though he and Crow both said their respective health systems don’t have plans now to pursue NCQA recognition.

Taylor said there are many platforms, including insurance, through which the medical home concept is advancing.

“Many payers are locking in patients, once again, to that medical home, (and) unless you’re directed to some type of care by your medical home, you’re denied preauthorization or have to go through a more rigorous process to get that specialty care or diagnostic test paid for,” he said.

Ready for reform
For all three health systems, the shift to the medical home concept ties directly to health reform legislation passed in March. Access, which can be improved with efficiency, is a key tenet of both, and health care homes also support reform goals tied to quality because they examine outcomes.

Fursa said the reform bill sets aside money for medical home pilots, but like much of the reform, he said the amount isn’t specified. And Halverson said the clinic is anticipating higher reimbursements for medical home practices as a result of reform, though it’s not yet clear what those would be.

All health systems are in agreement that in addition to improving patient care, the medical home concept stands to bring substantial health care savings.

Taylor points to specific evidence of such savings at OCH, which in 2009 was named the least-expensive Medicare hospital nationwide by U.S. News and World Report. According to the report, the highest U.S. Medicare co-payment was $6,397, compared to $1,169 at OCH.

“It’s because we’re built around this medical home model,” he said. “It works. It keeps the costs down.”

Still, St. John’s Crow said the shift to the medical home driven model won’t be easy.

“This is a battleship that’s been heading at high speed, and we’re going to have to remodel it and turn it at exactly the same time,” he said. “It’s going to be quite a challenge.”