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The philosophy behind the patient-centered medical home is to catch illness early on, manage already-sick people so they don't get much sicker and improve population health to reduce avoidable hospitalizations, emergency department visits and other costs. It's accomplished by putting primary care physicians in charge of a defined population to manage health proactively instead of reacting only to complaints of patients who come for office visits.

It's a nice vision. But consider the implications in total amount and scope of work to treat, prospectively monitor, effectively educate and delicately motivate masses of people for whom a medical home is suddenly accountable. That takes a whole new organization not only within the bounds of a primary care practice, but substantially outward into the surrounding community. And it takes new job titles and different job descriptions for existing personnel working under physician direction.

Call them care managers, patient navigators, case coordinators, health coaches. They're all variations on a theme around establishing closer relationships with patients both in and out of the office setting. With primary care, "sometimes it really is medical care that's required … but sometimes it may not be," says Mary Witt, senior vice president with the Camden Group. "Maybe it's education, maybe it's being connected to support systems."

"To manage outside the office, it really takes a team," says Frederick Bloom Jr., M.D., chief of care continuum for Geisinger Health System, an integrated delivery network in central Pennsylvania. "Our primary care physicians are overwhelmed with the number of responsibilities that they have, between acute care, chronic care needs and prevention needs of a population."

Primary care doctors can't possibly do all that themselves and, indeed, much of it doesn't require their expertise, Witt says. "It doesn't make sense economically for physicians to provide some of this care, when others could do it sometimes better, and certainly less expensively."

Geisinger in 2006 launched what it dubbed the ProvenHealth Navigator program, with the physician in the center but delegating aspects of the medical home's daunting scope of responsibilities that don't involve complex medical decision-making, including efforts to help motivate patients to a goal. The idea is to cover all the necessary ground in "taking care of a population of patients: those patients who are not in the office on your schedule, as well as those whom you are seeing in your office," Bloom says.

There's no one defined way of either organizing a system of care around these patient needs or staffing for it, says Pamela Thompson, R.N., CEO of the American Organization of Nurse Executives, an affiliate of the American Hospital Association, and a member of the AHA's primary care workforce roundtable. "It's really important to have the conversation start with what people in your community need." But one guiding principle in that conversation, she says, is "trying to maximize the use of all the health care workforce by having people work to the top of their skill level."

Not Just Nurses

To turn the traditional physician-centered, one-on-one interaction with patients into a more flexible and responsive medical home, some things only a physician might have done in the past are now delegated to mid-level clinical professionals such as nurse practitioners, advanced practice nurses and physician assistants. This is a boost for purely medical care, but it doesn't get at the wider responsibility of this model to proactively manage patients' health, including the social, economic and educational factors that affect how well they follow the care plans designed to improve their situations.

When the Hudson Valley Initiative in New York state launched a pilot project in 2009 to test a medical home model, the need for another kind of role became clear, says Annette Watson, senior vice president of community transformation at Taconic IPA, an organization of independent practices of which 15 participated in the initiative. There were well-functioning teams of physicians, NPs and PAs, "but everybody was doing visit-based, task-based care" and no one was assigned to bring up and monitor adherence to the comprehensive care plans previously developed for the patients being seen, she says. A new role materialized.

After considering what that role called for — among other things, comprehensive patient assessment, both clinical and psychosocial — registered nurses were tapped to be case managers for practices, says Watson. These assessments take a lot of time and skill, and that fit with the traditional nurse background and strengths. Nurses also are the medical team members typically spending face time with a patient, especially when care is more intensive.

As medical homes nationwide fill out their workforces, Witt says, the registered nurse generally is assigned to serve as the patient manager, focusing on those with chronic diseases and maintaining regular contact with them — checking their health status, making sure they're taking their medications and getting the care they need per their management plan. But just like the clinicians they support, care managers often delegate duties less dependent on their skill level to personnel working under them. These ground-level employees, often the first line of contact with patients, don't need nursing degrees to accomplish their work, and they're typically hired from neighborhoods where the patients live, Witt notes.

"It depends on what you're trying to accomplish," she says. "If I'm trying to talk to patients on a day-to-day basis about how they need to change their diets, how I help get transportation for them to be able to get to a doctor … oftentimes it's more helpful to have somebody who comes from the community, who understands what's going on and is able to translate what we're trying to do from a medical standpoint, and what the impact is if they do, or don't do, certain things."

For RNs who are managing cases at Geisinger, a lot of the work involves coordinating and scheduling, Bloom says. So, they've been given coordinators to nail down patients' appointments, arrange rides, "all those logistical things that really don't need a nurse, just somebody to help the patient, [and] who has a little bit of familiarity with medicine and the system."

In some emerging primary care models, personality trumps health care background. At Iora Health, a Cambridge, Mass.-based company that deploys four health coaches for every physician in an intensive ambulatory care approach, a coach needs only "a good attitude, good interpersonal skills and [a willingness] to learn," says CEO Rushika Fernandopulle, M.D. Some have backgrounds as nurses or medical assistants, but many do not. "We have coaches who used to work at Target and Dunkin' Donuts and restaurants," he says. "It doesn't matter where they come from — hire for attitude, train for skill."

Priority Patients

It's important to decide not only whom to deploy, but for what? When it comes to proactive management, two related truths are coming into focus: There aren't enough resources to fully manage all patients all the time; and a very small subset of patients accounts for most of the costly care, and thus the highest need for close management. That reality already has prompted a concentration among medical home physicians on the sickest of the sick; but it takes the added deployment and involvement of managers and coaches to complete those efforts.

At the outset of its pilot program, Taconic IPA hypothesized that a cohort of very sick patients in primary care needed the intervention of skilled, trained nurse managers, Watson says. These patients had "really advanced diseases that may be approaching terminal stages, or they needed a lot of aggressive intervention to either improve the clinical outcome or prevent things like frequent ED visits." A comprehensive care plan, which might include regular office visits, home care and other vigilance, could prevent unnecessary trips to high-cost crisis centers, she says.

Taking the same approach, Geisinger long has reserved its navigator force for the small number of people generating the most cost, Bloom says. That amounts to 15 to 20 percent of patients older than 65, and 5 percent of patients 65 and younger.

Iora closely manages every single patient in its practices because that's the point — it's dedicated to providing an environment specifically for the sickest and costliest members of a larger group, usually an employer, Fernandopulle says. From the physical design of a practice to its approachable coaches, the model emphasizes patient engagement. Comparing that with the usual primary care environment, he says management of the sickest is too different to be approached as part of an operation built for many grades of patient severity. "I think this works best if it's on its own. You need to handpick the right people, you need to break the usual rules."

Identifying the most promising targets for close management can be challenging, however. At Taconic, the health of some of the sickest wasn't going to be altered by any amount of management. Meanwhile, patients one level of severity down "weren't the sickest of the sick but had the potential to become more out of control — or become the sickest of the sick — if there weren't interventions to put in place," Watson says. "These patients were just simmering because they weren't utilizing the resources of the practice that the other people were taking up."

This next step down in illness severity was prime for the type of care coordination being deployed. "Education and coaching and developing a plan of care with those patients was an unexpected result [of the pilot] that we found very, very helpful," she says. "What we're finding is that over time, as you get the sickest people managed as best you can, the resources are then available to look a little further down the spectrum." Taconic's moves proved successful. Interventions allowed the highest-skilled clinicians working in teams to continue to be able to see patients with complicated conditions while nurse managers worked from care plans to keep abreast of certain patients in the office and direct them through a continuum of care outside the office, says Watson. Outcomes are still being analyzed for publication, but the pilot ended ahead of its planned run and opened up to all Taconic practices because the clinical indicators of managed patient populations clearly were improving faster than those that weren't, she explains.

Shrinking the 'Social Distance'

One reason the roles of manager, navigator and coach — originally split off from physicians — are being split into further variations on the managerial theme stems from the breadth of responsibility. The people in this emerging workforce have to interact and be credible with physicians on one end and patients on the other. They sometimes need a significant medical understanding, and other times a keen sense of how to motivate and empathize with people of limited means and no medical understanding. And they have to work with other care sites, community organizations, Medicaid offices, churches and more.

Genesys Health System in Michigan has a 10-year-old program that provides health navigators to a population of more than 25,000 uninsured adults covered by a state-funded and county-administered health plan in Flint and Genesee County. The care coordination program, called HealthWorks, originally chose only degreed nurses for their "ability to understand the clinical condition," says Tammy Merkel, vice president of performance excellence and clinical integration.

Most health navigators still are RNs, but HealthWorks leaders now are questioning whether they all have to be, Merkel says. For example, social worker Lisa Horne was hired three years ago as a navigator to work in the health system's inner-city, resident-training clinics and out of a downtown church, and her value to those settings highlights the importance of that skill set in reaching the low-income or no-income sick. "Health is influenced by broad determinants beyond the scope of just clinical care," Horne says. Motivating people to health is one of those determinants, she adds, calling a patient "the most important person on the team."

Social work is one of several professions making its way into the medical home to fill identified needs, says Witt of the Camden Group. Not only are social workers valuable in providing direct counseling to patients in the office, but they also are familiar with community support systems that patients may need.

Health navigators try to ensure that primary care physicians, hospitals, extended care facilities and patients are all connected, including transferring information from one location to another, Merkel says. "We set up some great systems with our health navigators so that if a patient is in the hospital, the health navigator is aware of it." They get discharge instructions, which are entered into the electronic health record of the physician to whom they report, and in the next several days they call patients, schedule follow-up appointments, and in the case of chronic illness, check that patients are following their care plans — "helping to remind them of all the things they need to do to stay out of the hospital," she says.

That end of the skill set — the close relationship with patients — is in many ways the opposite of the clinical mindset. Fernandopulle argues it's a different culture entirely. Engaging the patient won't be easy in the current primary care culture because there is "too much social distance between the doctor and the patient." Health coaches hired from the surrounding community "speak the language of the patients they're serving, really can help people with all the blocking and tackling it takes to manage their health," he says.
Whether it's through highly educated RNs, street-smart peer counselors, or many options in between, "We know that it is critical to have some kind of outreach to our patients when they're not in the physician office, when they're not in the hospital," Merkel says.

"And we're going to be spending the next many years trying to figure out what is the right pace for that, the right technique for that, the right person to be doing that," she adds. "Because the more we can support the patients when they're in their homes, the less we will need to see them in the hospital."

John Morrissey is a freelance writer in Mount Prospect, Ill.

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