DEC 11, 2012 2:27pm ET

Building a Firm Foundation for Medical Homes

DEC 11, 2012 2:27pm ET
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“The American Academy of Family Physicians is staking their whole future on the medical home,” Dr. Terry McGeeney told an audience of about 150 physicians at the AAFP’s Scientific Assembly in San Diego in September 2008. This assertion rattled me. Knowing I would be presenting at this same national conference in one hour, I started feeling somewhat uncomfortable. At that point, I had never heard of a “medical home,” and the AAFP was betting their whole future on it. I would soon be speaking at a national meeting for the first time in my professional career, and my thought was “Maybe I'm out of my league.”

As I continued listening to Dr. McGeeney, however, the comfort started returning. He described in detail the responsibilities of a medical home --access and timely communication with a familiar physician, a practice-based care team, EMR functionality, quality improvement benchmarks, coordination with other medical entities and population management. The relaxation grew because these were things we had been doing well in my practice for the past several years, but it certainly had not always been that way.

I started in primary care as a family physician in 1982 in Virginia. I worked solo for 12 years then joined a large hospital-owned physician group in 1994 due to multiple changes that made it increasingly difficult to remain independent. Since 1982, I had always been able to have a successful medical practice without sacrificing my family. I was an assistant clinical professor of family medicine at two medical schools, enjoyed my patients, and was very grateful to have been given the opportunity to work as a family doctor.

Things started changing significantly by 1998. I started experiencing negative impacts on both my practice and my personal life because of all the regulations imposed on primary care through the HMOs. I was working harder and making less, but the knock-out blow was yet to come.

My medical group realized, appropriately, that they needed to adopt electronic medical records. They were well ahead of the game when they started EMR implementation in 1996, and in 1998 I was their first high volume practice to be a part of this effort. I figured we would get through--no big deal. Boy, was I ever wrong!

For a guy who was computer ignorant--I could type about six words a minute-- this killed my productivity. It was like taking a life jacket away from someone struggling to swim in deep water a mile offshore. So by 2003, I was exhausted and drowning, financially and personally. I was working 60 to 70 hours per week, $80,000 in the red at the office, never able to catch up, very seldom available to my patients, hating medicine and, worst of all, had become a ghost to my wife. I would have left primary care if I could have, but at 51 I was too old to retrain.

So in 2003 I went to my boss, and told him I wanted to teach my R.N. to help me inside the exam room to see if we could change my present dilemma. He liked the idea, and let me hire another medical assistant immediately, and we began our journey of transformation. I made this change mainly to see more patients so I could pay the office bills. Two years later, our collections had gone up more than $100,000 per year. More importantly, we experienced a dramatic improvement in our quality measures. In addition, our patient satisfaction went up, the staff really enjoyed their work, and my work week dropped to 45 to 50 hours per week--and I could finally have unpressured time with my family again.

Seeing the success of the initial change, I hired another MA and a part-time R.N. in 2004, and for the first time in 10 years I had the necessary staffing to meet my patient’s needs. Once I built a team, it was easy to deliver primary care in a way that I always knew was the “right way.” Same-day access to a familiar physician, timely communication, competent care for acute and chronic needs, quality improvement, and population management were well known goals to anyone with a medical education, but not easily obtained. Now with the adequate staff and the productivity to pay for the staff under normal customary fee schedules, I was able to meet patient needs.

Listening to that presentation in September 2008, I realized the changes I had made since 2003 allowed me to function like a medical home without specifically trying. By developing this practice-based care team with my registered nurses and medical assistants starting in 2003, we had become much more effective at delivering quality primary care to my patient panel.

I left San Diego determined to complete an application to be recognized by the NCQA as a primary care medical home. Our application was received by the NCQA on Jan. 16, 2009, and in April 2009 we were awarded the first PCMH recognition in Virginia.

What change could bring such transformation to my practice – from drowning to becoming the first office in Virginia to be recognized as a PCMH? This change, in principle, is very similar to taking a nurse and giving him/her the specific training needed to assist a surgeon in the operating room. This model has worked so well in terms of efficiency and quality that I dare say that no sane person would choose to go into surgery without an OR nurse present.

The practice-based care team we developed, and have refined over these past nine years, functions inside the primary care “operating theater of performance,” the exam room. By having a clinical team member collect and document all of the patient’s medical data, I no longer touched the EMR during the patient visit. I only reviewed and signed off on chart documentation during appointment breaks or at the end of the day. I was able to devote my full attention to the patient, and accomplish the exam room visit much more efficiently and competently. I have now trained many other providers to: (1) spend less time in each exam room visit; and (2) be much more available to see other patients on their panel.

Only in primary care are nurses so underutilized. And because of this underutilization, primary care is struggling. We have a current and growing shortage of primary care providers. Why we didn’t make this change 30 years ago is hard to figure; perhaps we just operate in a culture that is too resistant to change. In any case I can tell you that having specifically trained nurses or MAs changed my practice and my life dramatically.

Peter Anderson, M.D., a practicing physician at Virginia-based Riverside Medical Group, formed a business in 2011, Team Care Medicine, LLC to train medical practices in adopting the Family Team Care® model. To date they have trained 200+ provider-led teams in the US Army’s Medical Home Pilot and six private sector hospital practice groups.

 

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