Q&A: Collaboration in the Medical Home: 'The Potential Is Endless'
By Richard Scott
July 17, 2012
When it comes to the medical home model, the primary care physician is like a quarterback – a leader in charge of the patient’s care formation. But like all successful quarterbacks, the physician is surrounded by a skilled team of players, each of whom brings a diverse talent set in the quest toward producing best-possible outcomes.
cal Network One, a health management service provider based in Rochester, Mich., has capitalized on the concept of team-based care as it pushes the medical home model to new heights.
This week, Medical Home Today
catches up with Erica Ross, BS, ACE, the clinical manager at Medical Network One, to discuss the benefits of coordinated care and how practices and health systems can achieve these lofty goals.
Medical Home Today: What is the importance of team-based care, as embodied, for instance, in the rapidly expanding concept of the medical home model?
The patient-centered medical home supports treating the whole person, not only the medical issues. Each team member with the lead of a physician champion has an integral role in the care the patient receives. Please see response to question #2.
MHT: Can you describe how you are involved in Medical Network One’s coordinated-care paradigm?
ER: I am the clinical manager at MNO. I oversee and assist care managers within the physician’s office to effectively deliver patient-centered care that treats the whole patient. MNO has trained its team of multidisciplinary clinicians as hybrid (complex and moderate) care managers and moderate care managers embedded in primary care practice units. Hybrid care managers are RNs and LMSWs who assist patients with a multitude of complex health issues. They provide education related to the patient’s condition, review labs and test results, provide medication reviews, identify and find resources for needed services and discuss medical questions.
Our moderate care managers are a team of registered dieticians (RDs), wellness coaches and exercise specialists. The RDs develop meal plans with the patients based on their individual needs and dietary concerns. They educate the patient of the effects nutrition may have on her overall health and offer support as the patient embarks on making nutritional changes.
The wellness coaches are LMSWs and LLPs who empower patients to look at new ways of thinking about their health and wellness. They focus not only on physical well-being but treating and helping the whole person.
All of our care managers work with the patient to determine care plans and detailed self-management action plans. Self-management is the core concept of all of the appointments with the care manager. Patients are encouraged to play a proactive role in making changes that positively impact their health. The care managers and patients work collectively to share in the decision-making process when it comes to the care provided.
MHT: Based on your work in these wellness programs, how have you seen patients respond to the extra “layers” of care, so to speak?
ER: Whenever a change is presented, patients can always be a bit skeptical. In my experience, patients are most engaged and eager to participate with additional services when the physician is on board and supporting these additional “layers” of care. Patients value and trust the physician’s recommendations and are more likely to follow through when the services are introduced in this fashion. For patients who have participated, the response has been overwhelmingly positive. They appreciate experts in a variety of fields assisting them to manage their chronic conditions on their own. They enjoy the extra time that is dedicated to improving the care they receive and find benefit in having services available to them right within the physician’s office. They are receptive to owning responsibility for healthcare decisions and are more likely to follow through with recommendations when this sense of “ownership” exists. They seem to enjoy being in the driver’s seat with setting goals for lifestyle changes and chronic disease management, as opposed to always feeling like a passenger.
MHT: What is most encouraging aspect about your (and your program’s) involvement with patients, as well as with treating physicians?
ER: As mentioned above, the most encouraging aspects of our program’s involvement with patients centers around:
- A team-based approach to care with a foundation composed of self-management. Patients are responsive to the care provided when they guide/have a voice in the care they receive. Patients and care teams are now focusing on being proactive about health care decisions vs. reactive.
- Embedding multidisciplinary teams in the medical home allows us to provide care, alongside the physician, to a multitude of patients.
- Supporting the initiatives of the medical home including coordination of care and individual care management.
MHT: What potential do you see when it comes to the patient-centered medical home?
With physicians and patients working collaboratively to change health care delivery the potential is endless. With implementation of the PCMH initiatives, the triple aim can be achieved – lower healthcare costs, improved health of populations/increased quality scores, and most importantly improving the patient experience of care!(To read about behavioral health interventions in the medical home, click here.)