Across the cityscapes, woodland areas and river valleys spanning the 105 miles between Margaretville and Carmel, N.Y., a meticulously constructed network brings together the full capabilities of the Health Quest system to offer Hudson Valley residents coordinated medical care with a patient-centered approach.
The complexities of 21st century health care are best addressed collaboratively rather than through traditional models that have physicians operating in silos, with little communication among them and other participants in their patients’ treatment. To embrace this evolving approach to care, Health Quest Medical Practice (HQMP) offers patients access to a closely connected network of multiple primary care facilities and numerous specialty locations, two urgent care centers, as well as three Health Quest hospitals: Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center.
Uniting so many locations under the same banner seems a Herculean task, but a physician-led advisory group has instituted several initiatives to place HQMP ahead of the curve in terms of patient care.
Charged with spearheading the operations and strategies of HQMP, the multidisciplinary Physician Leadership Council meets monthly to examine best practices as they relate to compensation, finance, health information management, quality and planning. Under the council’s guidance, HQMP has transitioned from obsolete fee-for-service models to a highly collaborative approach, explains Joseph Christiana, MD, FACC, Chair of the Physician Leadership Council.
“Quality care is one of the major endeavors in which all personnel are involved,” he says. “Health care is no longer about how many patients you see or how many procedures you perform. HQMP has embarked on a number of initiatives to further enhance the quality care we already provide.”
The Physician Leadership Council aims to develop streamlined strategies for connecting multidisciplinary care teams across the HQMP network, facilitating ease of referral and transition between inpatient and outpatient services. Also geared toward the collaborative model of health care, patients are engaged as the team leader. All of these initiatives unite to form the basis of the patient-centered medical home model of care.
Bridging the Divide
David Cho, MD, FACP, Chair of the Comprehensive Primary Care Initiative and Co-Chair of the Division of Primary Care at HQMP, Hyde Park Office
The first step to realizing the patient-centered medical home approach is ensuring all providers within the system are on the same page. Dr. Christiana quickly identifies disparate components of medical care as one of the major issues plaguing conventional care delivery.
“Care was often fragmented in the past,” Dr. Christiana says. “Patients would be admitted to the hospital today, discharged in a week, and none of the work would be followed up by their primary care physicians or any specialists. This led to readmissions that could have been prevented with improved coordination.”
System-wide access to a single electronic medical record (EMR) system provides 24/7 availability of critical information — including patient histories, office summaries and lab results — to physicians along any part of the care continuum. It also prevents the loss of information between primary care offices and hospitals.
“Health care has always had problems with information not following patients into the hospital,” Dr. Christiana explains. “Sometimes, entire workups would be duplicated because hospital physicians didn’t have access to patient records. Because we have EHR available to all hospital-based physicians and have coordinated that system throughout HQMP physicians, all office and hospital records are available for our physicians to see.”
The process works reciprocally as well. Following patients’ discharge from a Health Quest hospital, detailed records, discharge summaries, medication lists and recommendations for follow-up care are instantly uploaded onto the EHR for primary care physicians, specialists and the patients themselves to see.
HQMP family medicine physician Sharagim Kemp, DO, explains that once patients are discharged or referred to informed physicians, those providers are poised to initiate treatment.
“Because information is coordinated and organized accordingly, it can be distributed so specialists have access to it prior to seeing the patient,” Dr. Kemp explains. “We can forgo coverage gaps and ensure lab tests are conducted before specialist visits occur.”
Sharagim S. Kemp, DO, board-certified medical practitioner, provides patient-centered care in Rhinebeck, N.Y.
The patient-centered medical home model is an initiative championed by the National Committee for Quality Assurance (NCQA), which describes its transformative primary care model as “what patients want it to be.” Dr. Kemp notes that it achieves this purpose by emphasizing active patient participation.
Through inpatient and outpatient portals, patients have access to their EHR. There, they see detailed information pertaining to their medical histories. Dr. Kemp explains that the idea behind this is engaging patients in the process by empowering them with information.
“The model transforms health care so that it is centered on the patient, not the physician,” Dr. Kemp says. “The patient becomes the primary axis around which all services are coordinated.”
Dr. Christiana likens the model — which aims to improve overall outcomes by emphasizing preventive care — to a football team. Patients act as coaches, while physicians execute the game plan.
“Physicians are the quarterbacks,” Dr. Christiana says. “It’s a team approach — with patients at the center — but the physicians make sure everybody knows his or her assignment and is doing the right thing. In this way, we involve patients in their own care.”
In a stepwise process, developed by the NCQA, physicians are united in treatment plans designed for patients suffering from complex disease processes. For example, diabetes requires a multidisciplinary care team to address the myriad issues related to its progression. Dr. Kemp explains that certain objectives need to be met: hemoglobin A1C tests every three months, as well as annual podiatry and optometric exams. Via EMR, the care leader, who is often the primary care physician, can see whether patients received proper specialist care and were compliant with prescriptions and follow-up appointments.
“Reducing costs and improving outcomes have been the most difficult riddles in health care to date. Health Quest Medical Practice is uniquely positioned to achieve these goals because we have the infrastructure. Our strong information technology team has been able to offer integration among multiple primary care facilities and a network of specialty and preventive care sites. In this way, not only can we ensure safety and improved outcomes, but we can constantly move forward and act upon initiatives coming down the road, such as Meaningful Use Stage 2 and ICD-10.”
— David Cho, MD, FACP, Chair of the Comprehensive Primary Care Initiative and Co-Chair of the Division of Primary Care at HQMP
“The primary care provider is a critical component in patient-centered, coordinated care,” Dr. Kemp points out. “As much as cancer patients need oncologists, they need someone to coordinate the care plan. Cancer patients who also suffer from diabetes or thyroid issues may not always receive care for these problems from specialists. The whole focus is teamwork, and most importantly, it’s to coordinate care so that no one physician has to make all the decisions.”
Six pairs of eyes are better than one when it comes to patient care, and the patient-centered medical home model encourages safe, quality care by incorporating every moving part of the patient’s care team into one well-functioning machine.
“One issue is a lack of communication among all the physicians who care for a single patient,” Dr. Kemp notes. “There could be missing information and not enough cross-communication or coordination. The patient-centered medical home simplifies a very complex situation.”
Jill Quaresimo, RN, Care Manager, working to coordinate care to improve overall care, outcomes and patient satisfaction
Hypothetical situation: A colon cancer patient undergoes surgery to remove a cancerous lesion. After the procedure, this patient should have follow-up tests to identify the presence of tumor markers. If no one coordinates care among specialists, it’s possible that oncologists think surgeons have run the tests. Surgeons may think oncologists have run the tests. Ultimately, the patient suffers because simple follow-up tests haven’t been ordered, and a cancer that should have been caught was left unchecked.
Conversely, physicians may not have assumed other physicians performed the tests. Duplication is extremely costly and sometimes uncomfortable for patients. Care coordination and EHR prevent these situations as well.
There is no dearth of examples proving the merits of patient-centered, coordinated care. Dr. Kemp explains that HQMP’s care model offers a vital system of checks and balances.
“Two of the major problems in medicine are patient volume and huge amounts of data,” she says. “The whole point of medicine is to help people, but the truth is that sometimes information is lost, and when that happens, patient safety is compromised. The patient-centered medical home model sharply reduces the likelihood of this.”
Bonnie Olson and Karen Lester, Patient Service Representatives, providing quality service to patients
It also helps prevent unwanted medical services. For example, consider the cancer patient who has endured years of declining health, countless invasive and noninvasive procedures, as well as quality-of-life-reducing chemotherapy regimens. At some point, this patient, having the ultimate say regarding the direction of his or her treatment plan, may choose not to continue down that path. As a facilitator of this patient’s wishes, Dr. Kemp helps him or her achieve the desired level of care.
“The most important aspect of the patient-centered model is that the wishes, decisions and preferences of patients are met,” Dr. Kemp says. “If, at some point, patients decide they want to discontinue care, then their care is again coordinated predicated upon these specific wishes.”
Implementing this model ups the ante for providers and patients alike. The primary care physician, as well as any specialist involved in a patient’s care, must carefully explain disease processes, potential treatments and the involvement of other physicians, as well as patients’ role in ensuring they receive follow-up care.
At the same time, this endeavor seeks the active involvement of even the most noncompliant patients. Diabetic patients who don’t keep follow-up appointments or have annual check-ups also aren’t likely to show up for specialist appointments, according to Dr. Kemp. These are the patients who are admitted to the hospital in their 40s and 50s suffering heart attacks.
The information patients need is available for them to see at all times via EHR. As such, Dr. Kemp explains, emphasis is placed on their responsibility to digest that information and be ready to ask questions regarding treatment.
“It is daunting for some,” Dr. Kemp says. “They have to be honest, active participants in the process. They should be fully engaged in their health care, and we urge them to ask questions and ensure their questions are being answered.”
Jill Quaresimo, RN; Karen Lester, Patient Service Representative (PSR); Elizabeth Cross, LPN; Gyna Gonzalez, Site Supervisor; Loretta Hill, LPN; Althea Lutz, PSR; Bonnie Olson, PSR; and Elece Ferraro, Site Manager
Navigating the System
But while patients are encouraged to take greater ownership of their care, HQMP gives them every tool they need to succeed. In addition to EMR access, care coordinators — a major innovative initiative made possible by participation in the Centers for Medicare & Medicaid Services’ Comprehensive Primary Care Initiative (CPCI) — shepherd patients through the system, as well as through inpatient-outpatient transitions.
The Chair of the CPCI Project at HQMP is David Cho, MD, FACP, who also co-chairs the Division of Primary Care at HQMP with William Heffernan, MD. Dr. Cho explains that the first milestone in CPCI is to outline a budget. The funds are earmarked for strategic practices to facilitate better coordination throughout care facilities. At HQMP, the bulk of these funds are allocated to hire care coordinators, who are embedded within primary care facilities and who are critical in coordinated, complex care associated with patients with chronic or serious disease.
“Care coordinators work to better coordinate care across the medical neighborhood, which includes primary care-led post-discharge care,” Dr. Cho says. “They also help in the effort to identify the sickest patients who require more time and resources than many primary care providers working solo may be able to provide. In conjunction with multidisciplinary medical teams, care coordinators improve overall care, outcomes and patient satisfaction.”
Truly effective health care is contingent upon clearly presented health information in concert with medical intervention. With increasingly heavy patient loads, primary care physicians didn’t have time to sit with each patient, comprehensively addressing their problems and explaining the intricacies of medications.
“In the past, providers have been put in the trenches of navigating patients through their medical needs, as well as through necessary services within the system, but none of us really had the resources to do so,” Dr. Cho explains. “I’d love to spend time going over medications in a more detailed way or reviewing nutritional changes patients need to make in their diets. Therein lies the struggle primary care physicians have traditionally encountered.”
When patients meet with Dr. Cho for primary care exams, some may also consult with care coordinators, allowing patients unprecedented access to a medical professional with the time and expertise to guide them through the subtleties of their conditions and medications.
“Often, we instruct patients on how to take prescribed medications, but it’s difficult to verify whether they’ve picked the medicine up from the pharmacy and even more difficult to know whether they’ve taken it properly or at all,” Dr. Cho notes. “Care coordinators are a crucial resource in meeting this challenge.”
Bridging the Gap
Dr. Christiana and Dr. Cho review a patient’s test results to coordinate the best possible treatment plan.
Care coordinators are equally invaluable in transitioning patients from inpatient to outpatient care. After hospital discharge, patients often require complex medical coverage. For example, one of Dr. Cho’s patients required IV antibiotics and home nursing care following hospitalization. These arrangements are far too complicated for patients to make, so care coordinators ensured everything was in place before the patient left the hospital.
“A lot of patients who transition from hospital to home do so without a full realization of their capacity or lack thereof to maintain medical therapy their physicians have recommended,” Dr. Cho explains. “This is what care coordinators do. In this case, they coordinated all of the patient’s care and made it possible for this patient to go home with IV antibiotics and critical ongoing surveillance.”
Additionally, care coordinators address a major cause for hospital readmissions, Dr. Cho notes.
“From a hospital’s perspective, physicians send patients home with a list of medications to take and recommendations for follow-up care, but traditionally, that’s where it ended,” he explains. “Care coordinators access the list of medications, via our extensive EMR network, and reach out to the patient, often before discharge, to ensure follow-up appointments are set up and pharmacies are on notice to fill the prescriptions.”
The final part of the process comes as the care coordinator ensures primary care physicians have the discharge summaries, as well as information regarding which tests have been recommended for follow-up.
“This all happens prior to patients arriving at my office,” Dr. Cho says. “I’m not only prepared, but the bridge from hospital to the community has been traversed seamlessly.”
For more information, please visit www.health-quest.org/HQMP.