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Future Of Primary Care? Some Say ‘Medical Home’

Imagine a place where your doctor doesn’t keep you waiting, does keep you healthy, and works with a whole team of other health care professionals. Oh, and imagine that place makes the doctor’s life easier and health care cheaper.

In a nutshell, that’s the idea behind what’s called the “patient-centered medical home.” It’s an idea that’s spreading around the nation.

“I don’t mean to sound in any way demeaning to physicians, but think of the care your dog gets,” says Lisa Letourneau, a primary care doctor who heads a nonprofit regional health care collaborative in Maine that’s trying to build medical homes in the state. “Vets are very good at delivering patient-centered care. They know when the shots are due. They call you ahead of time. They greet you warmly when you arrive. They coordinate your needs.”

One of the places working to transform its physician practices into medical homes is Martin’s Point. It’s a large nonprofit primary care group practice with several locations around Maine, including its home base at the actual Martin’s Point at the mouth of the harbor in Portland.

“What’s become clear to all of us is that the expectations for primary care and the expectations and needs for people in the care system have changed enormously,” says Martin’s Point president and CEO, David Howes. “The expectations of people in primary care are that they will do a great job caring for people with chronic disease, and they’ll identify and know everybody for whom they’re responsible.”

But in the medical home, doctors are also supposed to be able to hand off some of the less specialized – and often time-consuming – tasks to others. The idea, says Letourneau, is to have everyone “practicing at the top of their license,” or doing what they are most trained to do. That should best serve the patients and the health professionals.

Made A Difference For One Doctor

So far, it seems to be working for Doug Couper, an 18-year veteran primary care doctor at Martin’s Point. One way he marks the change since becoming part of a medical home a couple of years ago is the bike wedged between the desk and wall in his small office.

“That’s one big thing: I can get here and back home during daylight hours on a bicycle,” he says, meaning 12-hour days are no longer his norm.

Another is the proximity of his nurse, Patty O’Regan. She used to sit down the hall and around the corner, at a nurse’s station. Now she’s at a desk right outside his office, where they can easily confer about their patients.

One way Couper says the team has made the practice more efficient is that he’s put Patty and his medical assistant, Trisha Welch, in charge of scheduling. “They can work with my schedule; they can finesse the schedule. They know where to put people in; how long certain people will need,” he says. As a result, it’s reduced patients’ waiting time.

Another way Couper has improved his efficiency is his use of the nonhuman member of his team: Martin’s Point’s electronic medical record.

He demonstrates from his desk: With a few keystrokes, he selects just his own patients from all those at Martin’s Point.

“So, I can see there are 130 patients whose blood pressure is not well controlled,” he says. “And then I can start manipulating this data.”

Now he calls up a couple of graphs. “I can rank those blood pressures. I can look at how long it’s been since the patient was last seen. I can see there’s a couple of patients for whom it’s been a couple of years since they were last seen,” he says.

And so he’ll have Patty or Trisha call those patients to schedule an appointment.

But even that’s not what gives the numbers-loving Couper his biggest thrill. What he really wants to show off is what’s just outside his office: a couple of bulletin boards with more charts and graphs he lovingly calls “the wall of knowledge.”

This is where Couper tracks the health of his entire patient population. He can tell you, for example, that 98 percent of his hypertension patients now have their blood pressure under control.

Patients Don’t Perceive A Change

Unless they happen to stop and look, most of this is invisible to Couper’s patients. That helps explain why, when you ask, most say they don’t perceive any change in how his practice is run compared to a couple of years ago.

“Everything goes like clockwork for us. We’re just content with all the care we get,” says Goldie McKenney, who was seeing Couper with her husband, Charles. They’ve been coming to Martin’s Point for care since the 1960s.

And Couper says that’s just as it should be. For most patients, nothing appears to have changed.

Patient Education

But for some patients, the medical home has meant access to services they didn’t have before. For example, as part of the medical home teams, Martin’s Point also has health educators, people like nurse practitioner Alicia Greenwald. She specializes in diabetes education. In fact, she says her nickname is the “diabetes queen,” and she even has a crown and cape she wears to some health fairs.

But what Greenwald does is anything but funny. Her job is to see patients who need more time to work through medication or even social issues connected with their disease.

This day, for example, she’s seeing a sprightly 88-year-old named Mary Coyne, who’s suffering from a common diabetic complication called neuropathy.

“She didn’t really know what the word was, and she didn’t really understand that feeling like bugs biting her was a symptom of neuropathy,” says Greenwald. “So she needed clarification on that, so that she knew she didn’t have bedbugs – which is what she was worried about.”

Will It Save Money?

While doctors and patients may be happier and healthier in Martin’s Point’s medical home, what will really determine the success or failure of the medical home in the long run is whether it actually saves money. That’s a big concern for Lisa Letourneau, who’s heading up the separate Maine medical home project. She says many of the ongoing experiments aren’t focused enough on costs.

“And I’m afraid that’s going to bite us in the end,” she says. “Unless we can demonstrate this not only improves quality and patient experience [but also] controls costs, we’re going to be stuck.”

But in order to really make that all happen – quality, efficiency and cost – there’s going to have to be serious attitude adjustments on the part of both doctors and their patients.

Doctors, says Martin’s Point CEO Howes, will have to get over the idea that they’re the only ones qualified to deliver medical care. “If we can’t help physicians to move from a place where they are the center of every decision that is made to a place where they can delegate and share decisions with trusted teammates, then this won’t work,” he says flatly.

Patients will have to do some compromising as well, says Letourneau.

“We are used to, in America, ‘more is better.’ We apply that to health care,” she says. “We assume that more health care is better, and it is not. And, in fact, it is often dangerous to us.”

You can expect to see more medical homes popping up around the country. The new health law includes funding to help more primary care providers transform their practices into care teams like those at Martin’s Point.

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