Optimization of the new PCMH neighborhood

by Matt Adamson

There are a number of care models now being explored to improve the manner in which healthcare can be delivered. Let’s take a quick look at a few of the well known options:

Accountable Care Organization (ACO): The ACO model has the ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory (outpatient) and inpatient hospital care and possibly post acute care. Further, ACOs have the capability to plan budgets and resources and are of sufficient size to support comprehensive, valid and reliable performance measurement. The ACO model is one of the latest designs for managing healthcare costs, especially Medicare costs, and is gaining traction among policymakers desperate to control costs and boost quality in healthcare.

Clinical Integration: Clinical integration is needed to facilitate the coordination of patient care across conditions, providers, settings and time in order to achieve care that is safe, timely, effective, efficient, equitable and patient-focused. To achieve clinical integration we need to promote changes in provider culture, redesign payment methods and incentives, and modernize federal laws. At its most basic, clinical integration might involve initiatives to improve coordination around a single disease, typically asthma or diabetes. At its most sophisticated, it might encompass fully integrated hospital systems with closed staffs consisting entirely of employed physicians.

Patient Centered Medical Home (PCMH) Neighbor: The American College of Physicians (ACP) believes that the effectiveness of the PCMH care model is dependent on the cooperation of the many subspecialists, specialists and other healthcare entities (e.g., hospitals, nursing homes), also called “PCMH Neighbors,” to achieve the goal of integrated, coordinated care throughout the healthcare system. The ACP states that the success of the PCMH model depends on the availability of a “hospitable and high-performing medical neighborhood” that aligns their processes with the critical elements of the PCMH.

It is interesting to look at these options simultaneously and think about what is really needed to improve care and lower costs in the healthcare system. From a clinical perspective, it is clear that within all of these models we need to harmonize all patient interactions with the healthcare system in a coordinated fashion. This is particularly important for those patients who need the most from the system—those with multiple chronic conditions who are actively engaging with a number of specialists and often have frequent interactions with hospitals, imaging centers, labs, pharmacists, etc. Coordination is what the medical home provides, particularly due to the role of the care coordinator within the medical home. This is a person who is the advocate for the patient, putting them at the center of the process and making sure that all of the good that comes from interactions with the healthcare system remain and, in fact, are enhanced while the not so good (overly prescribed and scanned patients, low adherence to care plans, etc.) are weeded out.

All options present elements that improve the healthcare landscape. The “PCMH Neighbor,” advocated by the ACP, is a great description of where we need to start, but the neighborhood as described is a little too exclusive. The health plan as an entity also has a lot to bring to the table—not just from the perspective of managing reimbursement and paying claims—but also in terms of the clinical process. Many would say “there goes the neighborhood” if the health plan were to pull up the moving truck next door in our PCMH neighborhood, but let’s take a look at the advantages of giving them the welcome-wagon treatment.

  • Health plans have data—lots of it. This information can create a great longitudinal record of patient activity and give coordinators a view into patient activity that can be very useful, particularly when this data is supercharged by clinical integration.
  • Health plans have powerful analytics tools. Health plans understand that data has to be used to recognize where interventions should be focused; there is no reason this cannot be enabled for the care coordinator to use too.
  • Health plans have care managers. These are clinical people who have been working for years to improve the health of their patients while trying to lower costs through the implementation of case and disease management programs. Let’s collaborate better with this group and use their capabilities and systems as a resource to fill the gaps within the care coordination process.
  • Health plans have skin in the game. The health plan wins if the neighborhood is successful, so it will want to use its assets to bring everyone’s game to a higher level.

Clinical integration can be made possible with the inclusion of the care coordinator within the PCMH neighborhood. The care coordinator is trained and solely dedicated to the task of implementing programs, following up on medication adherence, managing chronic conditions and ensuring the overall wellness of the patient through evidence-based interventions. Physicians are often stretched too thin and poorly reimbursed for this work to consistently provide these services to every one of their patients. To be successful, the care coordinator must be integrated and become a vital part of the neighborhood, armed with the necessary tools to be well connected to the other PCMH neighbors or key stakeholders.

The ACO’s use of clinical integration within the neighborhood—along with the payer—provides a great incentive for all neighbors to play well together. ACOs built upon this structure allow for greater efficiencies to be implemented within the overall system, providing even higher potential for lowering costs and improving care as a patient is transitioned from one caregiver to another.

If you were to take a good guess as to where the next successful ACO will spring up, you would be well served by looking for the neighborhood that has enabled strong clinical integration via a successful medical home.

Matt Adamson is Vice President of medical home initiatives for MEDecision.

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