The Patient-Centered Medical home was envisioned as a new method of both delivering and financing primary care. The goal is comprehensive care by a physician-led team that is personalized to the patient's own self-management goals developed in consultation with his or her physician. The team -- including medical assistants, diabetes educators, nutrition and pharmacy resources, mental health professionals and others -- commits to population-based care using an electronic registry and outcome tracking.

CSI Rhode Island

The transformation at Governor St. is part of a demonstration project called "CSI RI", the Chronic Care Sustainability Initiative in Rhode Island. With the assistance of a grant from the Center for Health Care Strategies, Rhode Island's Health Care Commissioner Chris Koller worked with Quality Partners of Rhode Island in 2005 to convene major purchasers of health care in the state, the two dominant health insurance providers and representatives of the larger medical groups that provide primary care to Rhode Islanders, including University Medicine. Recognizing the twin (and related) crises in primary care of professional burnout (21% of new primary care physicians leave primary care practice within 10 years of finishing residency training) and low rates of medical school graduates choosing careers in primary care, the CSI participants sought to align quality improvement goals and financial incentives also in order to improve chronic illness care in primary care settings. The project also sought explicitly to develop a payment model which will enhance the attractiveness and viability of primary care as a specialty in Rhode Island. By demanding that resources for the project be housed in primary care practices for the benefit of all of the practice's patients regardless of their individual insurance plans and that all insurers participate equitably (based on market share), the five initial practices were able to craft one of the country's first all-payor PCMH demonstration projects. The project includes contracts with BCBSRI, United HealthCare, RI Medicaid (through ConnectCare Choice) and Rite Care.

As a contractual obligation, the Governor St. practice was required to achieve the NCQA level 1 certification which was granted in June, 2009. Elements of this certification involve written standards for access and communication, electronic test and referral tracking, electronic prescribing and on-site care management by a nurse who is a UMF employee but fully funded by the project. As of April 1st, the practice has completed the self-assessment required to begin the process of certification at the next level.

Members of the team

In an effort to provide better information to the physicians, Governor St. office manager Gail Martin, nurse care manager Darlene Arthurs RN, CDOE and quality assistant Ann Suggs track physician performance linked to conditions of interest in the pilot project (diabetes, coronary artery disease and depression as well as smoking status). Each member of the front office staff and each of the medical assistants have learned new skills and have become a more active part of the treatment and reporting team during this process. A CSI Core team meets weekly to discuss, plan for and then assess changes in office function. The core team is then responsible for sharing innovations with the rest of the staff and bringing their feedback to the next team meeting.

Measuring (and sharing) quality outcomes

Physicians in the practice receive regular reports on their team's efficacy compared to other physician/MA teams and against target practice standards. What percentage of the patients with diabetes has had an ophthalmologic exam in the past year? How many have a HgbA1c below 7 or microalbumin levels at target? What percentage of newly identified patients with a diagnosis of depression have had appropriate follow-up and did it occur in a timely fashion?

The collection of data at Governor Street has been hampered by the lack of an electronic medical record. The other four pilot sites were already live on an EMR at the outset of the project. To their disappointment, each of the pilot sites has found that even state-of-the art EMR systems generally do not have registries that collect clinical data real time and allow for meaningful reporting. Since three of the five current pilot sites are (or will soon be) using eClinical Works, it is anticipated that the registry function within ECW will be significantly enhanced and streamlined going forward and "ready for prime time" by the time practices go live.

Data, anyone?

The main outcome measures of the CSI project are three-fold: Physician professional satisfaction, patient satisfaction and clinical outcomes. These outcomes are being studied by a research team from the Harvard School of Public Health through support from the Commonwealth Fund. It is hoped eventually that there will also be a cost benefit from 1) reduced ER utilization from ambulatory care sensitive conditions as a result of the enhanced access piece of the PCMH model and 2) reduced hospitalization and re-hospitalization rates as a result of the enhanced delivery of chronic care pieces of the model. Quality measures are already showing significant improvements. Data analysis shows reductions in Hemoglobin A1c and serum LDL in Governor St.'s diabetic patients compared to historical controls. All five of the CSI sites have been able to demonstrate improvement in their clinical measures.

Rolling it out