A medical home

A month or so after the sad events alluded to in this post, I adopted a new cat from the Hawk Creek Animal Shelter here in Willmar. One of the stipulations of the adoption contract was to bring my new kitty for a veterinary checkup within two weeks – not necessarily because there was something wrong with her but to get her into the veterinary system and make sure a medical file was established for her. As an incentive, the Humane Society of Kandiyohi County even provided a coupon for a free veterinary visit at one of half a dozen participating veterinary clinics in the area.

Everyone, it seems, needs a medical home. Even our animal companions.

The term “medical home” or “health care home” has been around for many years. It was first used back in the late 1960s to refer to a central place where a child’s medical record was archived. More generally, it means the location, usually a primary care clinic, where patients receive most of their ongoing care. Regardless of how you define it, though, we’re going to be hearing it a lot more frequently in upcoming months as Minnesota rolls out its new “health care home” model this year. Last weekend the Minneapolis Star Tribune featured an article describing how the concept is supposed to work:

While the national health care debate has become mired in an acrimonious mix of ideas and insults, Minnesota is moving ahead, putting in place the building blocks of a landmark 2008 state law designed to improve medical care, keep Minnesotans healthier and ultimately trim soaring costs.

The first of the big changes – the “health care home” – will debut July 1 and then spread across the state, with perhaps one-fourth of the state’s 700 clinics certified to offer their sickest patients this new model of care by 2012.

Go to Staples, 150 miles northwest of the Twin Cities, and you can glimpse at the medical future now. That’s where 11 family-practice doctors at Lakewood Health System are using the approach to see whether they can offer better and sometimes cheaper care for 524 patients with the most complex conditions.

Minnesota isn’t the only state doing this. There are currently more than 90 initiatives across the United States to implement a patient-centered health care home model, and at least one version of the federal health care reform bill contained funding for additional pilot projects. (I haven’t been able to find out whether this funding remains in any current form of the bill.)

At first glance, it doesn’t seem all that radical. Health care providers in Willmar have been using various pieces of the concept for quite some time – for instance, a collaborative project at Family Practice Medical Center to improve the management of congestive heart failure. The Willmar Regional Cancer Center is another local service that has adopted a form of the case-management model for caring for its cancer patients.

In the larger picture, however, it’s a very big deal for the promise it holds of transforming the way primary care is provided: more time for patients who need the most attention, more teamwork, better management of chronic conditions, and, ultimately, improved patient outcomes.

How, exactly, does the medical-home concept work? An in-depth article that appeared in the winter edition of Proto, the magazine of Massachusetts General Hospital, describes a medical home pilot project in Vermont, using the example of a man in his 30s newly diagnosed with diabetes:

Pre-medical home, he might have gotten a session with a nurse educator to talk about monitoring insulin levels and giving himself daily shots, and perhaps to go over recommendations for diet and exercise. But it would have been his job to make follow-up appointments to measure his blood sugar, and no one would have had time to check whether he was going to the gym and losing weight.

With the new system, he gets frequent calls and e-mails from staff members alerted by a computerized patient-tracking system. The team’s nutritionist has designed a reduced-carbohydrate diet and an exercise plan for the man, who meets with the team nurse monthly. He has lost 45 pounds and is managing his diabetes without insulin.

At Lakewood Health System in Staples, the physicians decide which patients should be assigned to a health care home. From the Star Tribune article:

Every medical home patient gets a doctor visit of at least 30 minutes, double the usual time. All 11 primary care doctors reserve several slots a day for medical home patients who need immediate care.

“We were getting frustrated. We didn’t seem to have enough time for the patients who needed us most,” said Dr. John Halfen, 60, medical director at the Staples clinic and the driving force behind the new system, now 16 months old. “I’m not working less now, but I feel like I’m accomplishing more.”

Depending on the patient, the health team might include a pharmacist, a psychologist, a specialist, a physical therapist, a home health nurse, the patient’s spouse, even a hospice coordinator or nursing home worker.

But it’s the care coordinator – a registered nurse and the first point of contact – who keeps the system humming.

The real clincher is that, starting July 1, health insurers will begin paying care coordination fees to providers to help support the extra resources they’re investing in medical-home patients. Lack of money has long been the stumbling block to providing more comprehensive care for patients when they need it, and it’s one of the reasons why most clinics simply haven’t been able to coordinate care to a greater extent.

If the medical-home concept works the way it’s supposed to, the money invested up front will be reaped in cost savings with fewer hospitalizations, fewer complications and better overall use of the medical system. Here’s more from the article in Proto (it’s a lengthy article, but if you want to learn more about the medical home model, I’d recommend taking the time to read it from start to finish):

Yet hopes are high that the medical home model could be at least part of the solution to out-of-control health spending, as well as addressing concerns about quality. A 2004 study by the Future of Family Medicine Project, a collaboration among seven national family medicine organizations, estimated that total health care costs would decrease almost 6% if medical homes became the norm, saving some $70 billion annually. And one major proponent of the model – the Patient-Centered Primary Care Collaborative, a coalition formed in 2006 by IBM and other businesses that has grown to include more than 700 members, including large employers, insurers, consumer groups and physicians – suggested in a report that the patient-centered medical home, “if appropriately conceived and properly implemented,” could transform the U.S. health care system.

Obviously we’re not there yet. But early results indicate the model does indeed help hold down costs – and both patients and clinicians are generally happy with how it has transformed the way primary care is provided and received.

If I have a criticism, it’s this: Most of the medical home initiatives, including the one in Minnesota, focus on those who are already sick, have chronic conditions or need a lot of care management. To be sure, this is a patient population that requires attention. By all accounts, the cost of chronic disease in the United States is going to continue rising, so it’s critical to manage these patients as well as possible.

But if one of the goals is to shift the focus of the American health care system from an acute care and disease intervention model to one of wellness and disease prevention, it’s hard to picture how this can happen when the model doesn’t include patients who are farther upstream – in other words, folks who are healthy to begin with and whom we want to keep healthy. Transformation needs to start somewhere, of course, and it makes sense to start with those who have the most complex needs. In the long term, however, I’m not sure how much change we’ll be able to accomplish if we continue to invest our resources primarily on sickness.

The medical home, in its broadest sense, refers to where patients receive most of their care, sick or well. Most studies have concluded that when there’s continuity, when patients have a health care team who knows them well, they generally fare better overall. But many Americans simply don’t have a health care home. Maybe they only see a doctor when they’re sick. Maybe they’ve never really established an ongoing relationship with a physician or clinic and don’t have someone whom they consider to be “their” doctor. If they’re uninsured, they’re probably outside the system altogether. Until we can bring more of these people into the fold, so to speak, I’m not convinced that American health care will truly be able to transform itself the way we envision.

So, back to my cat. I made the appointment at the same veterinary clinic where we’ve been a client for many years. The shelter gave me a copy of my new cat’s health and vaccination record, which I brought to our visit so it could be copied into her new medical file. We put her on the scale, with good news: Her weight is perfect (although the veterinarian informed me that we wouldn’t want it to get any higher). The scanty fur below her right ear suggests she may have had ear mites or an ear infection at some point, but both her ears now look entirely normal. There’s some tartar on her teeth, so she’ll need a dental cleaning some time this year. All in all, she’s a healthy and happy 5-year-old cat. She not only has a home, she also has a medical home and it’s going to be all to her benefit.

If we can do this for pets, surely people deserve no less.

Photo: Wikimedia Commons

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  1. Pingback: Rethinking the medical home | HealthBeat

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