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The IBD medical home: a holistic approach to specialty care
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The “patient-centered medical home” health care model presents a new way of coordinating patient care, focusing on the needs of the whole patient.
Also known as the primary care medical home, the patient-centered medical home (PCMH) is a health care model designed to meet most of the needs of the patients, including specialty care, hospitals, home health care and community services. The PCMH model also focuses on open communication and knowledge between medical home providers, patients, and their families.
Recently, this concept has been applied to medical homes focused on specific medical disciplines, with specialists acting in a primary care capacity. One such emerging system is the IBD Medical Home at the University of Pittsburgh Medical Center (UPMC). For suitable patients whose health care needs are primarily driven by IBD, this program offers enhanced care focused not only on the disease, but the entire patient.
“If these patients are young, healthy, and don’t have any other disease, we essentially act as their primary care provider,” Miguel D. Regueiro, MD, senior medical lead of Specialty Medical Homes at UPMC’s division of gastroenterology, hepatology, and nutrition, told Healio Gastroenterology and Liver Disease. “That doesn’t mean they can’t have a primary care provider — many of them will — but since Crohn’s and ulcerative colitis are their main problems, everything funnels through us as their medical home.”
Regueiro spoke with Healio Gastroenterology and Liver Disease about the emerging concept of the subspecialty medical home, how it can benefit patients, and the attitudes of gastroenterologists about such a shift.
Healio: The concept of an IBD medical home, or even a specialty medical home, is very new. How have you undertaken this model in your practice?
Regueiro: As far as I know, ours is one of the only groups doing this right now. The essence of this is that the gastroenterologist, as the specialist, becomes the principle care provider of a population of patients who have Crohn’s disease and ulcerative colitis. The goal — which is the ultimate goal of any health care reform project — is to improve the quality experience and the value of the patient experience while reducing utilization and cost. We call it a “total care program,” meaning that the gastroenterologist is providing total care for the patient, with other specialists providing care that more or less wraps around the patient.
Healio: How does the IBD medical home improve patient access to their gastroenterologist?
Regueiro: One of the principles for the medical home is that we basically have open access, or certainly easier access. If a patient is in the medical home and they need to be seen, we’d much rather them see us within a day than go to the emergency room. That’s the other part of this: In the past, patients would go to the emergency room because they couldn’t get in to see a physician. We’re really trying to have more of an open access through the medical home.
Healio: What has prompted adoption of the PCMH model?
Regueiro: I think it’s the changing environment and culture in health care delivery and health care practices that has really driven this: the idea of improving the value proposition and reducing utilization. Some gastroenterologists in IBD are realizing that if we don’t make this change, at some point we’ll be told by the payer or other entity that the way we practice medicine will change. I think those who are starting to get out in front of this are realizing that this may be coming down the line anyway, so why don’t we write the script and decide how care is provided?
Our medical home is part of an integrated delivery health care system with our own payer, UPMC Health Plan. We’ve aligned with our payer around this medical home, so we’re part of a payer-provider network.
Healio: Is your medical home meeting its goals for providing patient care?
Regueiro: We monitor patient satisfaction scores, and they’ve been extremely high because patients like the open access. They like the multidisciplinary approach. When they come in to see us or talk to us, we work on things like psychosocial stress and diet, not just their disease. They like the fact that we’re aligned with their insurance company. In essence, we’re working with them, and that’s streamlining care overall. Our outcomes in terms of quality improvement and decrease in ER visits, hospitalization, and cost have been positive.
Healio: An IBD medical home might not be right for all patients. Who might not be a good candidate for care at a PCMH?
Regueiro: Part of the enrollment at our specialty medical home involves determining whether IBD is the primary reason the patient is seeing a physician. If, for example, a patient has Crohn’s disease as their fourth diagnosis, and they’re also on dialysis, they’re a brittle diabetic, and they have very bad hypertension, Crohn’s disease is not likely to be their primary driver of health care. What we’re looking at are patients whose primary driver of health care is their Crohn’s or their ulcerative colitis. These are the patients who stand to benefit from an IBD medical home, for the same reason we’re probably not right for that dialysis, diabetes and hypertension patient. That patient should probably be coordinated with a true primary care physician who has more experience with those diseases.
Healio: There is a significant primary care element to the medical home model. Have some gastroenterologists or other specialists resisted the idea of participating in this type of care model?
Regueiro: Yes. I would say that as I go around the country and talk to other groups and other physicians, probably 90% do not want to do this care model, because there’s a non-specialist aspect of this. That’s not meant critically. I just think it’s a very different model than specialists are used to. The way we train, the way we prepare to be a gastroenterologist, a cardiologist or a pulmonologist, isn’t looking at the holistic or total care of the patient. It’s looking at one small niche. Most specialists go into a specialty because that’s what they want to do. This model is quite a bit different.
Healio: Do you think the shift toward PCMH models will be an inevitability?
Regueiro: I think when we’re talking about potential reimbursement changes for specialty medicine, and for possible capitation and costs around specialty care, this is a way to basically figure out how you can get to the table with a payer. My concern is that if we don’t address this, at some point the payer or the government will say, “You can do this much with this amount of money, but otherwise, you have to figure it out.” We’re ahead of that curve.
Healio: How might this type of model be adjusted for health care providers that aren’t aligned with a payer?
Regueiro: As systems look at population-based health care, they’re looking not only at what is in their backyard, but possibly at a region that encompasses many more miles. Many systems are starting to look at how to take care of a population insured by a specific payer, or how they can take care of a population that surrounds a certain area that is larger. What we’re doing is transformational medicine. We’re using technology, telemedicine, remote monitoring, working with payers, working with contracts and specialty groups to provide population-based health care that’s very different from what we’ve done before. We’ve learned a lot from small failures and small adjustments.
We probably will keep evolving and we’ll keep learning and other groups will do things differently and learn from each other, but I think in the next 5 years, this will transform health care delivery for specialty care — it’s a product we haven’t seen before. – by Jennifer Byrne
For more information:
Miguel D. Regueiro, MD, can be reached at 200 Lothrop St., Pittsburgh, PA 15213; email: mdr7@pitt.edu.
Disclosure: Regueiro reports no relevant financial disclosures.