The Case for Patient Centered Medical Home, Care Coordination and Population Health Wellness
The Affordable Care Act (ACA) is changing the way patients, physicians and clinicians interact with our healthcare system. At first glance, creating affordable 
healthcare for all is an amazing yet daunting initiative. In actuality, however, patients are now finding it difficult to get appointments with their overburdened clinicians, landing them square in the middle of an expensive emergency department (ED) visit. Many of these individuals have primary care clinicians but lack coordinated care management. They have real diseases, diabetes, HIV, congestive heart failure, just to name a few, but make frequent visits to the ER because… Because why? There is no one driving care coordination.
Here’s a real story. Although I only practice emergency medicine part time, I noticed that almost every shift I worked, either I or one of my colleagues would see the same patient repetitively. We are fortunate to have care managers in the ED but they are usually not available in the late evening so this patient was being seen, sometimes had a workup, sometimes not but was usually discharged and told to follow up with his primary care physician. He lives alone, has no social support system and has a real disease. Here is a man who should be part of a patient centered medical home, receiving coordinated care to prevent recurring ER visits. He, and many others like him, have fallen through the cracks. This patient was finally admitted, eventually accepting an assisted living arrangement, thus eliminating unnecessary visits to the ER and providing him a much better health and wellness solution. But could this have been done sooner?
This is not an isolated case. According to a February 2011 report from The National Institute for Healthcare Reform, “avoiding emergency department utilization is a goal of the patient-centered medical home; these tools appear most suited for coordination with ambulatory specialty care, rather than with emergency care providers. Nevertheless, as in all other areas where providers share responsibility for a patient’s care, lack of coordination between primary and emergency care can put patients at risk and potentially make the services delivered in both settings less efficient.” Thus, addressing the care coordination issues at the point of ER care with case managers taking an active role could certainly help this situation.
The pressures in healthcare reform, including changing reimbursement models, penalties tied to readmission, the increased importance of patient satisfaction, capacity management challenges, and competition pressures could be lessened by utilizing care managers. They could then arrange for follow up with the PCMH or primary care clinician so that patients do not fall through the cracks or suffer from lack of resource coordination. Resource utilization and readmission rates would improve. But most of all, population wellness would improve.
I know we are all trying to improve healthcare. In the words of my colleague, Dr Mark Crockett, CEO of RiseHealth and practicing Emergency Physician, by allowing our entire care coordination team to work at their highest level, we can enable the teamwork necessary to manage populations, reduce costs, improve patient satisfaction and improve care to achieve the Triple Aim. Sounds like a plan to me!
Let me know your thoughts! Follow me on Twitter @DrMarcieSC
