All of us who see patients at Duke Family Medicine Center are acutely aware of the incredible complexity of their care, the number of comorbid medical problems our patients have, and the astounding number of medications that many of them take.
We are also increasingly aware that it is very difficult to see these patients in a traditional 15-minute office visit as we have done for years. Given the deep personal commitment each of us has to providing high-quality care, how do we reconcile these pressures in favor of delivering an outstanding patient experience, including the best possible outcomes for the health and well-being of our patients? And how do we take care of ourselves while we do so. It’s time to talk about the Advanced Medical Home model of care.
Most of you are aware that we are recognized as a Level 3 Patient Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). You are also very much aware that we are doing many things, often at the same time, to try to improve our patient care processes, improve quality, and streamline our workflow. Some examples of these efforts include:
- Care process redesign led by the Red Team and the residents around type 2 diabetes mellitus care
- Improvements in pap smear screening and follow-up processes
- Improvements in our care for opioid-dependent patients
- Enhancement of the role our medical assistants can play in patient care and workflow, including advanced skills training
- Pairing nursing/medical assistant staff with providers on a consistent basis whenever possible, particularly for our busiest providers
Advanced Medical Home model of care
These process redesigns, and others to come, will move us from the PCMH model into what is known as the Advanced Medical Home model of care. This model is developing nationally as a response to the need for rapid-cycle improvement, and the need for an integrated team-based model of care that can innovate quickly, and one that focuses on the best possible patient outcomes.
A brief from the Advisory Board Company describes a medical home as having the following characteristics:
- Comprehensive care
- Enhanced access to the care delivery team
- Coordinated care
- Team-based approach
- Use of a disease registry
- Patient engagement
This same article goes on to describe goals for the Advanced Medical Home to include:
- Extended care team to include medical assistants and non-clinical staff
- Prioritize primary care provider (PCP) time for complex primary care cases
- Streamlined EMR workflow
- Reduced patient idle time
- Improve access, particularly through virtual contact
- Increased capacity for patient throughout
- Improved quality
- Decreased costs
Finally, they offer five steps to build the advanced medical home. I believe you will recognize what we are doing here at Duke Family Medicine from this list.
- Reevaluate care team tasks
- Elevate the medical assistant to a central care team role
- Help physicians prioritize patient interventions
- Capture data and educate patients while they are waiting
- Incorporate group education and caregiver support into the patient visit
Another description of this process as implemented by the Geisinger Health System (Pennsylvania) can be found in this Health Affairs article from 2010. This team initially focused their efforts on patients with chronic disease and multiple comorbid conditions (just like many of our patients). Key elements of their efforts included:
- A primary focus on the health outcomes of their patients
- Tying compensation for all members of the organization to achievement of patient care innovation targets and goals
- Inclusion of the elements of the PCMH model described above
- Development of embedded care management teams within the clinical setting, particularly for the highest-utilizing patients in the system
The following table describes some specific lessons learned from the Geisinger effort:
Creating an Advanced Medical Home at Duke Family Medicine
I’ve spent a fair bit of time discussing the Advanced Medical Home model in this post, and you might ask, “Why is she talking about this now?”
I believe that we here at Duke Family Medicine provide some of the most complex ambulatory primary care anywhere in the Duke Health system. (Stay tuned for some data we are gathering about that topic.)
I also know, because I see it daily, that we are all struggling to remain resilient in the face of increasing patient complexity, increasing pressure to focus on patient outcomes, and increasing attention to the bottom line.
Finally, I know that we all want to do the very best patient care possible – we are awesome primary care providers! It’s my belief that the Advanced Medical Home approach will allow us to do just that, while making our workflow and work-life easier.
Here are some of the things you are seeing that represent our attempts at creating an Advanced Medical Home at Duke Family Medicine.
- Training our MAs to work at top-of-scope for their training
- Enhancing capacity to provide acute care to our patients, with enhanced access, likely through a walk-in clinic that we staff. Getting X-ray back in the building and asking to improve stat lab access in the building are two key elements to this plan.
- Developing our CenteringPregnancy® practice as a way to improve patient access and patient outcomes related to pregnancy
- Developing a group approach to diabetes care to improve patient access and patient outcomes
- Ongoing rapid-cycle improvement around a variety of quality improvement issues
- We are working with the health system and others to see what can be done to pilot “encounter specialists,” specifically trained to work with our highest-volume providers to provide scribe services and help with workflow. More on this will be forthcoming over the next several months.
We are attempting several changes all at once, and the hope is not to increase chaos, but to move us down the road to improved patient care, improved provider experience of work-life at Duke Family Medicine, and overall better outcomes for all.
It is my hope that you will continue to bear with us through all of these changes. There is a larger plan, and it is geared toward creating Duke Family Medicine as an example of an Advanced Medical Home, caring for some of the most complex patients at Duke in a compassionate and comprehensive way.
Thanks again for all that each of you does every day to make this a great place! Please reach out if you have questions.
Sharon K. Hull, professor and chief of the Division of Family Medicine, can be reached at sharon.hull@duke.edu.
Editor’s note: Dr. Hull guest blogs the first Friday of every month.