4 ‘key ingredients’ to develop a specialty medical home
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SAN ANTONIO — There are four key elements to success in creating a specialty-centered medical home – smart medicine, meeting unmet needs, team ‘buy-in’ and long-haul cooperation with insurance and institution – according to an expert at the American College of Gastroenterology Annual Meeting 2019.
“We start small and build larger,” Miguel Regueiro, MD, chair of the department of gastroenterology, hepatology and nutrition at Cleveland Clinic, said during the David Sun Lecture. “The neighborhood concept of how we link all together through these paradigms will lead to population health in a way we have not actually seen before.”
Regueiro explained how the IBD Medical Home at the University of Pittsburgh succeeded and how he is seeing the same trends in Cleveland where he is beginning to work on an “IBD Neighborhood” around Cleveland Clinic.
He said the first ‘secret sauce’ to medical homes is the care of patients by understanding the interactions between biological and environmental factors in the mind-body illness interface.
If considering a specialty-specific medical home, physicians must consider a population of patients whose principle care is from a specialist. For instance, hot spotting analyses showed that patients clustered to tertiary centers near metro centers. In his example, Regueiro showed that one hospital sees most of the patients with Crohn’s disease and just 34 patients utilized $10 million in costs.
So the other consideration must be a partnership with a health plan around that disease state, which must be a chronic disease spanning at least 5 years and focused on decreasing utilization so as to increase return on investment.
“We put together with the health plan at the time this medical home concept, which was really a team-based approach to care to see if we could fix in terms of value equation and quality while reducing costs.”
The outcomes from Pittsburgh showed targeting those high utilizers gave the greatest return.
“The patients with the highest disease activity we could impact the most” in terms of disease remission and, at the same time, “The total cost of care goes down,” he said.
Smart medicine
Regueiro said the specialty physician must be smart about how he or she practices medicine, by using all the tools available.
He said it starts from the first phone calls.
“We try now to embed more schedulers and navigators on the phone. The interesting thing is the narrative of the patient’s journey in the medical home really starts with that personal contact, the person on the phone who is embedded on your team who understands them.”
Unmet needs
Then the medical home must look at the needs that are unmet by the specialty care.
“We simply need to ask the patient what are the top three problems they have today and what are the top three things they want out of this visit,” Regueiro said. “If we don’t ask our patients what they want and what they need, our visit and our focus is very different.”
Oftentimes, he said, the biggest problems are not their specific disease state, such as IBD. The patient will often tell you the other things in his or her life that are most frustrating, resulting in them seeking medical attention.
By caring for the whole patient and creating a multidisciplinary approach, they are more satisfied overall.
“Psychosocial care and dietitians by the way are one of the two key components of any medical home,” he said.
Team buy-in
And when medical homes integrate various disciplinaries, the team must continually touch base and work together to maintain the dedication.
“This really is old fashioned team-based care. Team-based care is the other secret sauce, if you will of a medical home,” he said. “If we don’t work within teams and we work in silos or as individuals, this is where the care models break down.”
Regueiro said they use the huddle – a quick touch base to formulate an understanding from the whole team about a patient’s care. It’s that team mentality that also helps prevent team burnout, he said.
“My fear was we were going to see this high-utilizer group of patients and wow the burnout is going to go up,” Regueiro said. “If anything – we haven’t formally published this yet – we are seeing lower burnout. Why? Because you’re not an individual taking on a problem. You’re a team taking on a problem. When you are a team takes on a problem and you have different members at different levels, that becomes a very satisfying equation.”
Long-haul cooperation
It’s that long-haul cooperation within the medical home and between the medical home and its institution, payer, insurance, etc., Regueiro said, explaining that they just launched a Medical Neighborhood last month in Cleveland by leveraging technology. It’s now not one center, but a region of care.
“As we are using more digital technology, we are able to reach patients not only in our own back yards but across large spans. We are able through e-consults or different platforms, to work in this medical neighborhood,” he said. “This is going to be the answer. ... The final secret sauce in what I consider a medical neighborhood is we must leverage technology. There’s no way the way we practiced medicine in the past will exist.”
Yet, it must remain simple for the physician – easy referrals that start as e-consults, automated care gap registries and virtual visits.
“Between the visits is when the patient spends most of their lives,” Regueiro said. Telemedicine – even “good old fashioned” phone calls can help patients.
“These telemedicine and delivery models through digital technology really are disruptors that will change medicine in the future,” he added. – by Katrina Altersitz
Reference:
Regueiro M. The David Sun Lecture: The IBD Medical Home and Neighborhood. Presented at: American College of Gastroenterology Annual Meeting; October 26-30; San Antonio.
Disclosure: Regueiro reports financial relationships with AbbVie, Amgen, Celgene, Janssen, Miraca Labs, Pfizer, Salix, Shire, Takeda and UCB.