A Medical Home Vision and Some Lessons Learned from the Front Line by Matt Adamson

If you read our blog with any regularity, it has probably become readily apparent that we at MEDecision are very excited about the prospects and potential of the Patient-Centered Medical Home (PCMH). We believe very strongly in its ability to enable better patient care at a lower cost and, over the past year, have devoted significant resources to developing technologies that will enable it to succeed. Our vision for the medical home takes into account the following considerations:

1. While some aspects of care management will remain with health plans, their role will change as that responsibility begins to shift toward the medical home team.

2. All patients are unique with individual sets of circumstances. That will require many different approaches toward the delivery of care.

3. With different approaches comes the need for care coordination to steer all of the moving parts and manage tasks according to the patient’s needs.

4. Maintaining different technical systems and organizations for managing silos of case, disease, utilization and behavioral health management will become less prevalent within the health plan. Instead, care management efforts will take a more holistic approach through technologies and teams that are centered on the patient rather than the process.

5. Health plans will expect care management platforms to support the extension of their patient-centered processes to physician practices.

6. Health plans will also look to help create and support Accountable Care Organizations (ACO) around high performing medical homes.

As these factors emerge, it will mean that, in order to be effective, care management platforms can no longer simply be payer-based or exist only within the walls of a single entity. These solutions must be re-imagined and extended so that care coordinators in the medical home and the various other team members involved in a patient’s care (including the patient) can take ownership of tasks within the overall care plan and see the results in a timely manner. This creates a virtual medical home team that can be customized or shifted to account for the diversity of patient needs. The concept of a transparent care plan could then lend transparency to reimbursement models for physicians. Enablement of the medical home is also viewed as a methodology to address issues of the looming primary care physician shortage and increase the level of trust and communication between patients, payers and providers.

To date, MEDecision has been involved in a few PCMH initiatives with its customers, including an important medical home pilot project with Blue Cross Blue Shield of Oklahoma (BCBSOK). While the initiative remains in its earliest stages, we have compiled some critical intelligence points that offer health plans valuable insight when considering similar endeavors:

1. Identify the right provider practice. An effective medical home pilot requires the involvement of a provider practice large enough to generate outcome metrics that are significant and worthwhile. At least one third of the practice’s provider panel should be health plan members, and the practice itself should be a trusted partner with a genuine interest in pursuing the medical home model. It is also beneficial if the practice currently uses an electronic medical record.

2. Develop an effective reimbursement strategy. It’s important for health plans to work with the physician practice to determine the optimal mix of care coordination fees, fee-for-service, and shared savings reimbursement methodologies.

3. Consider technology as a critical component. The technology solution partner selected to help enable the PCMH should:

• Include proven analytics tools to identify gaps in care, delineate populations and support quality reporting.

• Enable the health plan’s nursing staff to drive care management processes closer to the patient through the medical home practice.

• Offer electronic medical records, such as MEDecision’s Patient Clinical Summaries, for use at the point of care.

• Improve provider communication and administrative efficiencies.

• Facilitate a medical home-centric health information exchange.

4. Devise a care management plan. Working collaboratively, medical home participants can determine the answers to a series of important questions in advance that will help smooth progress once the pilot project has been launched, such as:

• How are gaps in care being identified, and who is responsible for closure?

• How will case and disease management programs be managed? Will the health plan support the practice, or will it maintain responsibility—but with better communication?

• How can better collaboration with the pilot site be established to facilitate faster notification of referrals into programs?

5. Create legal and marketing strategies at the beginning of the process. Legal considerations should encompass changes in provider contracting and agreements on the specific responsibilities of and expectations for each participating entity. It is also beneficial to promote the medical home pilot through press releases and other appropriate marketing channels. Participants should come to an agreement beforehand on what the messaging should convey.

We’re very proud of the progress we’ve made in our medical home endeavors at MEDecision so far, and we’re really excited about where the future will take us. What about you? What are your thoughts on our medical home and the things we’ve learned to this point?