Health TeamWorks

Patient-centered Medical Home Pilot

The stop watch ticks as a patient navigates from the front desk to the exam room during a visit to the doctor.

Minutes are lost as the patient waits and waits.

Most doctors do their best to provide outstanding patient care every day. Few are brave enough to invite in outside analysts to help them turn their practices upside down – viewing every minute from a patient's perspective.

That's exactly what is happening in Colorado with grants from The Colorado Trust and The Commonwealth Fund, and an evaluation by the Harvard School of Public Health. Over the past year, 17 medical practices along Colorado's Front Range have been revolutionizing their care models by putting patients first. A team of providers works to give each patient a "home," an approach to health care where everyone knows them well and can work together to chart a course for better health.

Among the strategies they're using: open scheduling to free up same-day visits; a focus on wellness and prevention, rather than simply treating illness; and state-of-the-art technology to improve communication, give patients email access to providers, cut errors and increase care coordination among health professionals.

Data is one of the main drivers in this turnaround.

For example, doctors never used to know which of their patients frequently visited expensive emergency rooms. Now, thanks to better communication with insurance providers, doctors can identify these patients, contact them and explain that they can get better, faster, less expensive care at their doctor's office – rather than at an ER.

"They can say, ‘We have extended hours. We have open slots. We can see you.' It changes the dynamic. It's expensive to visit an ER for an ear ache,'' said Julie Schilz, who harnesses both her MBA and nursing training as manager of the Patient-centered Medical Home Pilot  for the Health TeamWorks (formerly the Colorado Clinical Guidelines Collaborative). "If someone is having a heart attack, we want them to go to the ER. But when consumers are in doubt, we want them to call us. Let's figure this out together."

New payment models, where doctors are rewarded for keeping patients healthy rather than treating illnesses, have freed some providers to hire care coordinators who focus on follow-up and results. They seek to provide "evidence-based care." Put simply, results matter.

"The practices measure what they do by gathering clinical metrics to make sure they are improving outcomes,'' Schilz said.

In the past, health providers would do their best to treat a patient, then would send them out the door. They never knew if the patient followed up with a care plan, visited a specialist, had a positive experience or became healthier. Under the medical home model, the practices are constantly collecting data and seeking input from patients. As painful as criticism may be, they're learning to make changes based on feedback.

The practices also have opened their minds to business models once thought antithetical to medicine. Take those stop watches, for example. Analysts from Health TeamWorks use them to study work flow in what's called "cycle time mapping." The best businesses have long made customer service their cornerstone. As a result, top manufacturers often analyze how their work flow directly contributes to higher customer satisfaction. In a medical practice, mapping time has uncovered redundancies and patient frustrations. For instance, both a medical assistant and the doctor may be asking the same questions. The mapping buys more time for every team member and allows everyone to work at their highest levels, or what the medical home experts call the "top of the license."

Innovative new concepts are springing from each of the pilot practices. For instance, group visits are becoming more common. Some of the providers are bringing together all their patients with diabetes. The patients meet together for education sessions where they can trade health tips and form support groups. Each of the patients will then see their health provider one-on-one for personal matters and individual assessments.

The group visits save time and money. But they also increase the likelihood that patients will stay healthier. "Studies show that patients can be more successful if they know they're not alone,'' Schilz said.

To further build bridges, the pilot program is reaching out to non-traditional support networks. These have included community recreation centers and churches. "We're viewing primary care as a hub that interacts in a medical 'neighborhood," Schilz said. "We're working with all these organizations to help support primary care and better understand how providers can build bonds with patients."