Building the medical home requires incremental steps

Recently a colleague from IT who is working with us on our patient-centered medical home asked me, “when is the rollout date for your patient-centered medical home?”

As we have gone through this process for the past six months, I can definitely answer that there is no one day when this is going to happen. We are not going to close the door one night, turn out the lights, shut down the computers, go home and go to sleep, to return the next morning to a fully formed patient-centered medical home.

Nor, I have discovered, are we going to get there by only taking the dozens, hundreds, thousands, of incremental baby steps towards our goal.

A recasting of the registrars here, a new way to collect data at registration, a new registry for high-risk patients, a new routing slip for our referral specialists.

I know now it is going to have to be a combination of both of these things, incremental tiny changes, and monumental, enormous, phenomenal, transformational changes.

Take for instance the example of our resident/registrar referral process. This project was created by one of our residents to improve the way our high-risk patients get their referrals and follow-up appointments, with a focus on getting people appointments before they leave the practice, including follow-up appointments with their primary care doctor or their team coverage.

This project is near and dear to the central tenets of the patient-centered medical home, catching those high-risk patients, improving continuity of care, and possibly improving our patients’ ability to get into the specialist care we want for them.

The current system is challenged and suboptimal, because our referrals go to a large electronic task list to be worked on long after the patient leaves. Patients end up receiving a notice in the mail recommending they call some phone number to schedule their own appointments. You can imagine how patients with complex medical issues may be challenged maneuvering the system of appointments, and we’ve discovered they make it to very few of the referrals we will send them to.

Streamlining this process — by doing today’s work today and having a specific team-associated registrar there to get the patient follow-up appointments made at the time of their office visit — will undoubtedly improve patient care. Although it does not ensure that they get there to those appointments (that is another project, where our care coordinators will contact them to assist them with actually getting to appointments), this will be a good start.

Our goal is to have this resident project, and the change that it will bring about in our processes of care, become integrated into our daily workflow, and seamlessly added to our electronic health record.

Until we are able to fully implement this, however, we are reverting to an old pen-and-paper solution. Bright yellow paper sheets are being printed up with the information the residents want conveyed to the registrars for our high-risk patients. They will bring these to the team registrar at the end of the visit to schedule follow-up appointments and referrals.

These forms will be collected by the registrars, collated at the end of the week, and the data will be entered by hand into an old-fashioned spreadsheet.

Someday this information will automatically be collected from the electronic health record as the patient goes through the process of their visit. Inclusion in the high-risk patient registry will automatically send their referrals and follow-up appointment requests to their team registrar, and by the time the patient arrives at the front desk for check out this information will be processed. But those days are not here yet, and IT is way behind, buried under an avalanche of high-priority projects.

And yet this is one of those baby steps. This is one tiny little cog in the enormous patient-centered medical home build process. These small changes add up to big changes, and big changes lead to transformation.

The big change comes from above. Engaging leadership, at both the medical college and the hospital level, and ongoing meetings to focus on our progress, will ensure that this transformational change can occur one step at a time, and many steps all together.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, New York. He blogs at Building the Patient-Centered Medical Home

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  • Robert Bowman

    PCMH appears to be a great choice if you can get grants, if you have higher income types of highly educated patients, if you have many on private insurance and others with higher pay.

    As you move down the SES scale you move toward lesser paying insurance, Medicare, Medicaid and no pay. You also move to higher turnover of personnel requiring more consultant and orientation time as well as lesser productivity. You move to patients less likely to be able to utilize the high tech approaches and you actually need more people and more people who understand the patients and their cultures and backgrounds – something that the payment system does not cover since you are paid less.

    PCMH seems to be best for about 30% of practices caring for U.S. patients who have few or no barriers to care. For the 30% of practices caring for Americans most left behind, matters may be worsening due to even higher cost of delivery with stagnant revenue. Then there will be the problem of more penalties – because they take care of Americans left behind in any number of dimensions that impact their health outcomes.

    Health care design cannot fix Americans. Social determinants and situations must change for cost, quality, and access improvements in education and in health care. Let’s try not to make matters worse with Common Core and Meaningful Use and PCMH and hospital readmissions – driving off more dedicated teachers, nurses, and primary care team members.

    • buzzkillerjsmith

      I don’t know about 30%. I don’t have a good handle on the percentages. But you and I agree that it will be wickedly hard even for those that make the transition. And It could be demoralizing as docs who are caught up in all this realize they could have done something else in their professional lives, something easier, or at least no harder, for a lot more money.

      All this mess is so wrong-headed. The way, the only way, for primary care to be fixed is to pony up much, much more money to induce docs and NPs and PAs to do it. I also think that handing the evenflow over to CorpMed to skim and distribute is absolutely insane.

      I’ve been wrong before. Time will tell. But I would not be surprised if a decade from now we see New York Times articles declaring the PCMH a rank failure in terms of money saved, outcomes improved, and percentages of med students who going into primary care. But really, who could have predicted it?

  • southerndoc1

    “Engaging leadership, at both the medical college and the hospital level, and ongoing meetings to focus on our progress, will ensure that this transformational change can occur one step at a time”

    Sounds like the exact opposite of patient-centered to me.

  • buzzkillerjsmith

    Doing today’s work today. What if doing this requires 50 to 60 hours per week for 60% of the income of a subspecialist? And then the same the next day, And the next. And the next….

    I shake my head.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      If I am not mistaken, the story is about a resident staffed outpatient clinic owned by an academic center. I don’t think your numbers apply there…..