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Only One Structural Change Will Make a Difference: Part II

March 2, 2011
by James L. Holly, M.D.
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To do the medical home 'right,' it takes a full-time care coordinator

The provider must be intimately involved in the patient’s life. A new data base will be required for this work which will include:

1. A living will on the basis of which to help the patient and family make rational choices about end-of-life issues BEFORE the time when they are required.

2. Special needs such as assistive devices which will be used to improve the patient’s health and not to make then an invalid prematurely.

3. Barriers to their receiving care whether economic, social, religious or other.

4. Designations of medical power of attorney and response to emergencies such as evacuations.

5. Coordination of care reviews which will address preemptively preventive care issues and problems which could compound care needs such as fall risk, pain assessment, functional assessment, etc.

The patient must be empowered to assume responsibility for their appropriate and rational care by education, training and information. A “coordination-of-care-review” document need to be provided to the patient, which alerts them to needed and un-provided care. Patients must have life-style issues addressed at every encounter, particularly in regard to weight loss, exercise and tobacco avoidance. Medications being taken and allergy reviews must be completed and documented at each encounter. Every patient encounter for an acute or chronic health problem must be transformed into a preventive health and health maintenance opportunity.

However, there is a catch. This transformation does not come without a price. To do Medical Home “right,” it is my estimate that it will take a full-time care coordinator – which will be a new employee to a medical practice -- for every 1500 active participants in Medical Home. In addition, a MSW (social worker) will be required for every three care coordinators. For SETMA, which essentially cares for 4,500 patients who would be initially “enrolled” in a Medical Home, it would require 4 new full-time, well-trained people along with active participation by healthcare providers and support staff to make it “work.” It is expected that it will take 12 months to initially create the database. After that it can be maintained and new people added concurrent with initial care.

The above is calculated on the basis of a care coordinator giving ninety minutes of attention per year to facilitating, tracking and monitoring the care of each person in their unit. The MSW will be available for home assessments and counseling in more complex cases. It is expected that 20% of the Medical Home members will need this level of attention, giving the MSW 2.2 hours per year with each of this group.

Weekly care-coordination conferences will be held about active, unsolved coordination of care problems identified by healthcare providers, support staff, care coordinators or MSW. Those conferences can be held with lunch being provided so that it maximizes the time utilization of all members of the team.

Because SETMA has a hospice and a home health agency, resources from these agencies can be pulled in as needed by the coordinators. And, the physical therapy department can also be involved.

A THOUGHT: I don’t believe for a minute that Medical Home is going to decrease the work of primary care providers and shorten their days Increased satisfaction? Yes. Improved outcomes? Yes. Cost improvement? No doubt. Less work? In the words of the Scotsman who was buying a used car from a man. When he asked the man how much he wanted for the car, his response to the answer was, “Silly boy!!!”

This is the structural change which must take place if all of the President’s goals are going to be achieved.

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Comments

Larry,
Thanks for your interesting post.

I am a little confused by the statement, "Cost Improvement? No doubt."

Can you share estimates of the relative infrastructure costs to the actuarial medical care savings projections?

James Holly

CEO, managing partner of the Southeast Texas Medical Associates (SETMA) in Beaumont

James L. (Larry) Holly, M.D., After completing his medical education, James L. (Larry) Holly, M....