Care Transformation Center Blog

Not seeing medical home ROI? Try these 4 recommendations.

by Megan Clark

Last month we sat down with Chief Medical Officers Lisa Bielamowicz, MD and Dennis Weaver, MD to talk about how organizations were continuing to advance the medical home.

In case you missed it, here are the four key takeaways from the discussion.

Pace medical home expansion to support health system growth

Both Lisa and Dennis noted that systems today tend to underuse medical homes to drive health system growth—specifically in making the system easy to access and maintaining a robust referral network.

First, the medical home can play a pivotal role in access, not just in making it easy for patients to get a face-to-face visit but also in supporting patients between visits with easy communication platforms or virtual access channels.

Second, medical homes offer a clearer picture of referral patterns. For many health systems, this analysis reveals that out-of-system referrals are much greater than expected. By better aligning cost and quality goals across the continuum, streamlining referral pathways, and improving specialist access times, systems are reducing leakage and seeing volume improvements.

Redefine panel size metric to reflect the care team

Although we often look to panel size as a metric to inform PCP capacity, population health may push systems to redefine the metric or look for more meaningful metrics of overall population management.

Panel size under-represents patient mix or complexity. As some health systems create high- or low-risk clinics, panel size should vary tremendously and reflect the different demands on physician time.

Panel size also tends to focus on PCPs only. Team-based care is the biggest lever to expand the total population under management. Systems are either redefining panel size around the team or adding metrics to review overall team capacity.

Make the medical home a realistic goal regardless of practice size

At this point and time, practices of every size have successfully navigated to medical home operations. For smaller practices, the key is often aligning with hospitals, health systems, IPAs, or even other practices in the region and creatively using resources to support care management.

For example, rotating care team staff across practices. Offices can schedule patients in need of additional care management support on specific days to meet with the team. Or, make a more proactive handoff from the PCP to the care team by having the PCP talk to the patient in advance about a care manager reaching out.

The most successful systems don’t just share the care team talent, but also the technology and analytics infrastructure to ensure seamless data sharing and prioritization of patients with the greatest need for proactive outreach.

Reallocate medical home tasks to generate care team ROI

In the first wave of medical home transition, leaders focused on offloading tasks from PCPs to RNs. RNs were the "utility player" in the medical home, partnering with physicians to develop a care plan and engage patients in next steps. However, as medical homes continue to advance, systems are revisiting care team task allocation to ensure RNs are kept at top-of-license too. MAs and LPNs can play a critical role in supporting both RNs and PCPs.

For example, MAs can work with patients in the practice to collect information, help during the visit, and offer additional coaching and education after the visit. MAs can also help with pre-visit planning and coordinating follow-up steps.

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