Treating IBD in medical home reduces costs.
In the midst of the ever-increasing costs of patient care for chronic disease, one model for care of a specific, complex condition is the medical home, according to a presentation at the American Gastroenterological Association’s Partners in Value meeting.
– REPORTING FROM 2018 AGA PARTNERS IN VALUE
The medical home concept came out of pediatrics and primary care, where patients’ health care needs could vary greatly over several years but benefited from coordinated care, Miguel Regueiro, MD, AGAF, professor of medicine and chair of the department of gastroenterology, hepatology, and nutrition at the Cleveland Clinic, told attendees at the meeting.
The medical home is ideal for a disease such as inflammatory bowel disease because it brings together the different care providers essential for such a complex condition and allows for the kind of coordinated, holistic care that’s uncommon in America’s typically fragmented health care system.
The two key components of a specialist medical home are a population of patients whose principal care requires a specialist and a health plan partnership around a chronic disease. The major attributes of a medical home, he explained, are accessibility; comprehensive, coordinated care; compassionate, culturally sensitive, patient-and family-centered care; and team-based delivery.After initially building an IBD medical home in Pittsburgh, Dr. Regueiro brought the concept to Cleveland Clinic and shared with attendees how he did it and the challenges and benefits it involved.
He advises starting with a small team and expanding as demands or needs dictate. He began with a GI specialist, a psychiatrist, a dietitian, a social worker, a nurse, and three in-house schedulers. The patient ratio was 500 patients per nurse and 1,000 patients per gastroenterologist, psychiatrist, and dietitian.
Dr. Regueiro explained the patient flow through the medical home, starting with a preclinic referral and patient questionnaire. The actual visit moves from intake and triage to the actual exam to a comprehensive care plan involving all relevant providers, plus any necessary referrals to any outside services, such as surgery or pain management. The work continues, however, after the patient leaves the clinic, with follow-up calls and telemedicine follow-up, including psychosocial telemedicine.
The decision to include in-house schedulers is among the most important, though it may admittedly be one of the more difficult for those trying to build a medical home from the ground up.
“I think that central scheduling is the worst thing that’s ever happened to medicine,” Dr. Regueiro told attendees. It’s too depersonalized to serve patients well, he said. His center’s embedded schedulers begin the clinical experience from a patient’s first phone call. They ask patients their top three problems and the top three things they want from their visit.
“If we don’t ask our patients what they want, the focus becomes physician-centered instead of patient-centered,” Dr. Regueiro said, sharing anecdotes of patients who came in with problems, expectations, and requests that differed, sometimes dramatically, from what he anticipated. Many of these needs were psychosocial, and the medical home model is ideally suited to address them in tandem with physical medical care.
“I firmly believe that the secret sauce of all our medical homes is the psychosocial care of patients by understanding the interactions between biological and environmental factors in the mind-body illness interface,” he said.