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Unifying a Patient-Centered Medical Home

April 3, 2012
by Jennifer Prestigiacomo
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The Adirondack Pilot makes strides in coordinating patient care despite interoperability challenges
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In upstate New York, where an aging population of primary care providers is leaving the workforce faster than new PCPs can be recruited, community leaders have founded the Adirondack Region Medical Home Pilot Program to increase emphasis on primary, preventive, and chronic care, as well as improving patient communication. Coming together as a patient-centered medical home (PCMH) however has not been without its challenges, which include interfacing clinical information systems and aligning incentives between payers and providers.

In 2009 the CEOs from the three major healthcare systems in Upstate New York, Adirondack Medical Center, Hudson Headwaters Health Network, and CVPH Medical Center [Champlain Valley Physicians Hospital], met to address the dwindling number of PCPs in the area. The program was designed to improve the care coordination and management of patients through a PCMH model, with the implementation of interoperable health IT.

Before the Adirondack Region Medical Home Pilot officially kicked off in January 2010 as a five-year, $9 million joint initiative of medical providers, Medicaid, and seven private insurers, New York State antitrust legislation had to be passed. A Medical Society of the State of New York (MSSNY) grant provided early technical and infrastructure assistance and capital funds, while consulting services from East Point Health helped bring guidance to the project. In July 2011, Medicare joined the pilot for three years.

More than 200 clinicians are organized into three geographic pods across the Adirondack North Country region—the Northern Adirondack pod (Plattsburgh and surrounding communities), Tri-Lakes pod (Saranac Lake and surrounding communities), and Lake George pod (Lake George and surrounding communities). Pods have weekly, monthly, and quarterly calls and meetings to update each other and share best practices.

“One of the things that really has been highlighted is you have such a huge region that covers the entire northeast portion of New York State, and we’re really working together, even though we’re not necessarily integrated, and we’re not in any way affiliated,” says Karen Ashline, director, Northern Adirondack Medical Home Project. “It’s just the fact that we’re sharing information about how to better provide transitions of care and how to cut costs over a wide region.”

Karen Ashline

Pilot practices have an increased emphasis on primary and preventive care, improved coordination of care and management of chronic diseases, improved communication with patients–including patient reminders for check-ups and screenings—and use electronic health records and electronic prescribing to adhere to quality and safety standards. Last December, all 31 primary care practices in the program, which include hospital and non-hospital employed physicians, were recognized as Level 3 Patient- Centered Medical Homes—the highest level achievable—from the National Committee for Quality Assurance (NCQA). Physicians receive incentives for coordinated care, while some of the incentives funnel back to the pod to provide for shared care management, social work, and IT services.

“Those small practices were really struggling, so this incentive that they’re receiving to now participate in a patient-centered medical home, has both helped them stay afloat and stay in our community,” says Ashline, “but also provide some additional support for their patients.”

Embedding Transitional Care Nurses
To aid in its mission to better coordinate care, the Adirondack pilot utilizes transitional care nurses to give post-hospital discharge support to patients to aid in preventing readmissions. At CVPH, there are three transitional care nurses that identify patients that need help, reach out to their PCPs, work with the pharmacy on the medication reconciliation process, and do home visits as needed. “We have reduced the preventable readmission rate at CVPH,” says Ashline. “That’s probably where we are most robust.”

The Adirondack pilot also focuses on chronic care, including diabetes, hypertension, and coronary artery disease, which were chosen based on region-specific clinical and insurance claim data. In the last three months, Ashline says two care managers have been embedded in practices to focus on diabetics, while six staff members have been trained to be chronic disease self-management peer-to-peer trainers.

To keep up with the IT demands of the pilot and allow connection to the Health Information Exchange New York (HIXNY), Mountainview Pediatrics had to switch EHR providers (to the Poway, Calif.-based MDsuite, which they had on the practice management side already) in August 2011. This pediatric practice, like the others in the pilot, focuses on asthma and childhood obesity.