Medical Homes

David Clark sat in an ambulance for hours late Saturday night in front of the Park Slope Armory in Brooklyn. Mr. Clark, who is 48 and relies on a wheelchair because of diabetes and a leg injury, was late to receive his medicines. But he still had not even been admitted to the armory, which was a designated shelter for patients with special medical needs who had been displaced because of the storm.

Here's my latest column from the Altarum Health Policy Forum:

Over at my “home” health policy blog at the New America Foundation, I’ve written (here and here) about the Robert Wood Johnson Foundation’s Aligning Forces for Quality project, which has challenged and assisted 17 communities across the country to do a better job in managing chronic disease and reducing disparities. I thought it would be useful to take a closer look at one of these initiatives, “Better Health Greater Cleveland.”

Better Health, which began in February 2007, involves more than 20 stakeholders including health systems, hospitals, payors, and state and local government. More than 45 participating physician practices -- most of which have electronic health records that allow tracking and measurement -- take part in learning collaboratives, and report on outcomes and care twice a year in the  “Community Health Checkup.” Those online reports are clear and accessible, with features like a cyber “gold star” for outstanding -- and improving -- primary care practices. (Click here to Better Health Greater Cleveland in action.)

Several of us from New America spent some time at the Agency for Healthcare Research and Quality’s big annual conference this week, its first since health care reform with all its potential for primary care was enacted. It’s a bit hard to sum up (keynote speaker Atul Gawande called it being "in the trenches with the data") so I’ll jump off from the opening plenary -- "21st Century Health Care: What Does it Mean to Achieve Success in Quality, Value, and Access to Care."

AHRQ director Carolyn Clancy (we had a chance to talk to her this summer here) moderated, and the panelists were Maulik Joshi, president of the Health Research & Educational Trust and senior vice president for Research at the American Hospital Association, James Mold, professor and director of research in the Department of Family and Preventive Medicine at the University of Oklahoma College of Medicine and Debra Ness, president, National Partnership for Women and Families (and the fact that Ness was there, keeping the focus on what patients/consumers/families want, was itself telling).

The discussion started with the observation that "patient-centeredness" is a bit of a Rorschach test, but panelists agreed (more or less) that people want coordinated care from someone who knows them, and can treat the whole person, not just an organ or a condition. They want to be engaged, and share in the decision-making. And getting there is tough.

The Washington Post this weekend had a human interest story in the Metro section -- a 110-year-old woman reunited with her 85-year-old daughter, who had been in a nursing home for the past three years. The mother Eddye Williams is believed to be Washington's oldest citizen. They are able to live together again in their home because of an innovative program by Washington Hospital Center that provides home-based care for sick elderly people, including house-calls by a physician and a home health aide under a Medicaid waiver. It's a touching story, of family, faith and medicine, but what really caught our eye is that it's a wonderful example of what health care can look like under health reform.

(This post first appeared on the Altarum Health Policy Forum. In a future post I'll tie it into advanced medical homes and other aspects of health reform  that address the needs of  the chronically ill and the elderly.)

Transitions are one of the weak points in the U.S. health care system. Poor coordination and inadequate communication around transitions is particularly pronounced in the care of frail elderly people with multiple chronic diseases -- or maybe an acute illness or injury on top of a whole big bunch of chronic diseases.

Wishard Memorial Hospital in Indianapolis is a large urban safety net hospital serving largely low-income people, many of whom are “dually eligible” for Medicaid and Medicare. Led by geriatrician Dr. Steve Counsell, the hospital has been developing a multi-pronged strategy to improve care and care coordination for this at-risk population. The programs have a smart approach to the shortage of geriatricians, leveraging the skills of geriatricians and geriatric nurse practitioners to support, not supplant, hospitalists (inpatient) and the primary care doctors (outpatient) caring for at-risk patients.

Abstract: The U.S. health care system too often falls short in delivering effective primary care, especially for patients with chronic conditions. One potential solution is the patient-centered medical home, a model that has shown success in individual demonstrations. Evidence from seven of the largest medical home pilots shows that four factors are essential: dedicated care managers; expanded access; performance management tools; and effective incentive payments.

Community health centers play a vital role in our health care safety net, but they are often overlooked in our national conversation. Luckily they weren't overlooked in the health reform legislation -- community health centers get $11 billion. What do they need to overcome barriers to care, give vulnerable and underserved populations the care they need, and plug in some of the gaps in the primary care system? A new report from the Commonwealth Fund, Enhancing the Capacity of Community Health Centers to Achieve High Performance, has some answers.

Pennsylvania Gov. Ed Rendell, an enthusiastic backer of national health reform and a leader at the state level through his Rx for PA initiatives, spent some time talking with health care writers here in DC this week courtesy of Health Affairs. Rendell, a Democrat, said he would have preferred that the national legislation had stronger cost control components, and pointed out that his own state had learned that it is in fact possible to lower costs while improving quality and safety. He specifically spoke about these state achievements or new initiatives:

• The state's Medicaid program (and I'm guessing maybe that includes PA's state children's health insurance program but he didn't specify that) will not pay for "never events." Not paying doctors and hospitals for things that absolutely should not happen, such as amputating the wrong limb, is a "tremendous incentive" to make sure they don't happen. 

The New America Foundation's health policy program has a new director for a new era. Kavita Patel, MD, MS, is a primary care physician who has more than ten years of policy experience, working on national health care reform at the Senate's HELP Committee and in the White House Office of Intergovernmental Affairs and Public Engagement. She has a particular interest in developing national policies to support innovation in health care delivery including payment reform and quality improvement. She also still loves practicing medicine. In her first post, she writes about medical homes -- an area where her policy interests and her priorities as a physician overlap.

Since the passage of the historic law affectionately known as PPACA, we have seen a flurry of activity, including Health and Human Services Secretary Kathleen Sebelius's call to end insurance discrimination against women with breast cancer, encourage private plans to allow young adults to stay on their parents’ plans until age 26 and really push the envelope to narrow the administrative costs of health insurance plans so that more of each premium dollar is spent on patient care.

(Reposting -- the Take Care Clinics are run by Walgreens)

CVS Caremark a few days ago announced plans to double its in-store Minute Clinics -- and also try to move beyond flu shots and strep tests and do more chronic disease management (diabetes, high blood pressure, asthma etc). Walgreens is eying partnership with a hospital or hospitals regarding future growth of its Take Care Clinics. (For more details on the business end of this, see this Business Week/Bloomberg story or this WSJ blog item.)

Coincidentally -- both I and my colleague Julie Barnes just a few days earlier had our first Minute Clinic experiences, for flu shots and strep throat. Both of us lived to tell the tale. Julie had a bad sore throat on a weekday morning when her regular doctor wasn’t in. She went to the CVS, and yep -- it was strep. She walked right over to the pharmacy counter, picked up her antibiotics, went home. The only minor flaw, she pointed out later, was that although the clinic had the capacity to communicate electronically with her doctor, and her doctor does have electronic medical records, Julie didn’t have the necessary information on her to have the clinic send the information. It will be up to Julie to fill the doctor in on what drug she took, and other relevant information, next time she sees her. And we hope providers soon figure out how to communicate by secure e-mail, but in the meantime Julie knows that she needs to keep the necessary info in her wallet for the future.