Coordinating Care In The Primary Care Office

Lately medical homes, accountable care organizations and population health have been three models of care receiving more and more attention. There seems to be some confusion about what these terms mean and how they can be used to improve our healthcare industry.

I have recently spent time educating patients, insurance companies and brokers, and, most often, self-insured employers about these models. All of these stakeholders are very interested in the move from volume (fee for service) to value for financing healthcare. They are hopeful that these models will increase the health of their constituents while slowing down the ever-rising costs. However, they are skeptical of how that will practically be delivered on the front lines of healthcare.

In this editorial and a couple to follow I hope to improve others’ understanding of how value is delivered through these models in primary care offices. I have developed a Value in Healthcare 101 dialogue that explains these models and their potential benefit. The underlying theme for each of these models is the concept of utilizing care teams to coordinate care.  For simple explanation purposes, I put care coordination into three buckets.

First, in order to improve the health of our patients we need to ensure they are receiving quality care. This is often referred to as filling gaps in care and can be as simple as making sure that women with a higher risk for breast cancer are screened for mammograms, or that a diabetic patient has all of his or her important numbers under control. For example, less than 20 percent of diabetics in the U.S. maintain target levels for sugar, blood pressure and cholesterol simultaneously. Imagine if this number was increased to 50 percent.

Secondly, the transition of patients from the emergency department and hospital back to the outpatient setting has traditionally received little attention. The result has been a high percentage of readmissions to hospitals and bounce backs to the emergency room. Having a system to ensure that patients are contacted and even seen in the office setting or their home shortly after discharge can drastically reduce these readmissions and set the patient back on course to stability.

The final category is management of high-risk patients. This type of care coordination is the one that gets the most attention, and rightfully so. High-risk patients can often be included in the prior two categories as well. These are patients with several chronic diseases who utilize multiple specialists and medicines and are often in the emergency department or hospital. The opportunities to improve their quality of care and be more efficient with healthcare resources through care coordination are incredible.

In 2009, Village Health Partners was the first certified Medical Home in Texas. It’s been our experience throughout the past several years that utilizing a physician-led care team to coordinate care is the best way to achieve the triple aim of improved health, cost control and high patient satisfaction. In my next couple editorial contributions I will dive deeper into some of the above strategies to continue the dialogue on care coordination. 

—Dr. Christopher Crow is a founding doctor of Plano’s Village Health Partners and creator of Legacy Medical Village.   

Posted in Expert Opinions, Physicians.