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Medical homes model spreading slowly11/19/2010
'Medical homes' model spreading slowly
November 19, 2010
Dr. Cliff O'Callahan doesn't just keep tabs on his patients when they come to his office. The Middletown pediatrician fields e-mails and telephone calls from his patients' parents. He and the nurses and care coordinator in his office keep track of patients' visits to specialists. And anytime he gets a call about a particular patient, O'Callahan can pull up relevant medical records on the laptop he carries with him.
O'Callahan's practice is a medical home, a model for coordinating patient care that has been gaining attention nationally but is still in its infancy in Connecticut, according to a report by the Connecticut State Medical Society.
The idea behind the medical home concept is that keeping track of patients' health--making sure they take their medications, manage their health and can easily get help from a medical professional when they need it--will improve health and save money by staving off acute problems that can strike if chronic conditions are not well-managed.
It's part of a shift that must occur in medicine, from caring for people when they are sick to caring for them when they are well, said Dr. David S. Katz, the medical society's president.
"You don't want people calling you with chronic illnesses when they're sick. You want to keep your pulse on the situation and keep them from getting sick," he said.
While use of the full medical home model is limited in Connecticut, the medical society's report, based on a 2009 survey of 498 primary-care physicians, found that elements of medical homes are already used in medical practices.
Thirty-nine percent of primary care doctors reported using electronic medical records, and 33 percent said their practices kept registries of patients with chronic diseases; another 25 percent said they plan to in the next year.
Even more common among practices was "open access scheduling," in which some appointments are left open in a physician's schedule each day to accommodate patients with urgent needs. Wait times for the 56 percent of doctors using the method were 35 percent shorter than in offices not using it -- 9.9 days for a visit, compared to 15.3 days.
Other elements related to care coordination were less common. For example, less than 25 percent of the doctors surveyed said their practices have or planned to have nurse care managers for patients with chronic diseases.
During a press conference on the survey results Tuesday, O'Callahan pointed to barriers to more widespread adoption of the entire medical home model.
"It takes a lot of work," said O'Callahan, a board member for the Connecticut chapter of the American Academy of Pediatrics. "It takes a ton of my time outside the office, and that's not billable time."
According to the survey, smaller practices were significantly less likely than larger ones to have adopted the more costly and complex aspects of the medical home.
Matthew C. Katz, the medical society's executive vice president, said the survey results are not surprising, particularly since the majority of medical practices in Connecticut have fewer than five physicians. Electronic medical records can cost thousands of dollars per doctor to implement -- although the federal government has committed billions of dollars in funding for doctors who use them -- and care coordination can require additional staff.
"Solo and small-practice physicians have a hard time paying for these changes in their practice," Katz said.
The medical society's report, published in the journal Connecticut Medicine, noted that doctors might look to different practice models to be able to afford electronic medical record systems and team-based care. Those could include sharing staff, consolidating practices or other types of affiliations, such as with hospitals or independent practice associations, that give doctors access to more resources.
The report also cited insurance practices as a potential barrier to adopting the medical home concept, noting that few doctors in Connecticut are paid for the additional work required to coordinate patient care.
Some insurers in other states have embraced the medical concept, as have some large employers. SustiNet, the health plan being developed under a universal health care law passed last year, makes use of medical homes, as does a pilot program in the state's Medicaid program, HUSKY Primary Care. And the state developed plans for a demonstration project on medical homes for state employees and Medicaid and Medicare recipients, although an application for federal funds to do it was not granted.
State Sen. Jonathan Harris, co-chairman of the legislature's Public Health Committee, said it is crucial to focus on the issues raised in the the medical home report and an earlier medical society report that warned of a shortage of primary care doctors. While the earlier report presented workforce needs, the medical home report points to the infrastructure necessary to move the health care system forward, he said.
Harris, D-West Hartford, said the state can have a key role in pushing forward the model, in helping provide access to federal dollars and private grants, and in making sure that policies driving other health care issues are in line with promoting medical homes.
It will be a long-term effort; implementing medical homes will take five to 10 years, or more, he said.
"The next couple of years are without a doubt going to be filled with triage and making some really tough decisions," Harris said. "That doesn't mean that we should forget this issue. As a matter of fact, it's more important that when we make these tough choices, we make them with this model in mind in how to best move us forward."
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