January 04, 2012

Bend Memorial Clinic (BMC) began implementing the region’s largest Patient Centered Medical Home (PCMH), a model based around proactive, coordinated and preventive care, in January 2010 with a test group of nearly 4,000 Clear One Medicare Advantage (now PacificSource Medicare Advantage) members.The goal of the program is to better manage the health of patients, to avoid hospitalizations, proactively reach out to patients for key preventative care, better manage care, manage costs, and assist patients in monitoring and managing their chronic conditions.

BMC’s PCMH program resulted in reduced hospital admissions and Emergency Room visits in 2010.

“Recent studies have shown that the medical home model is an effective method to improve healthcare while also reducing costs and improving patient satisfaction,” said Dr. Sean Rogers, BMC’s Medical Director and practicing Internist. “Essentially, patients will receive better care by both preventing complications arising from manageable chronic diseases, such as diabetes, heart conditions and high blood pressure, while increasing availability of same-day appointments when office visits are needed. A physician-led team focuses on managing all care needed by the patient.”

The BMC PCMH program model is led by a Primary Care Physician and includes Midlevel providers, Hospitalists, a Pharmacist and Nutritionist, all Internal Medicine Clinical and reception staff and a Nurse Care manager. BMC implemented the following changes to support the PCMH:

Same Day Appointment Access – All primary care Providers schedules were changed to have Same Day appointments for patients.
Medical Home Teams Formed – Physician led teams were formed and include receptionists, medical assistants, nurses, mid-levels, Hospitalists, Pharmacists, Nutritionist, Nurse Case Manager and other support personnel to provide comprehensive and coordinated care for the patients.
Quality Data – Key quality data metrics were determined and a data warehouse was built to collect measure and monitor patient’s health.
Nurse Care Manager – A Nurse Care manager was brought on board to coordinate and assist in managing the chronic care of patients.
Preventative Disease Registry Developed– A staff member proactively calls patients and assists in scheduling appointment for necessary preventative screenings.
Patient Outreach – Through both the preventative disease registry and the Nurse Care manager, patient outreach became a core part of the PCMH program to ensure that patients have someone from BMC navigating their healthcare.

“From a health plan’s perspective, working closely with BMC has been instrumental in enhancing the communication between the physicians and the health plan to ensure our members receive the care and services they need at the most appropriate time for them,” said Dr. Mark Maddox, PacificSource Medical Director. “We are now playing an active role in the care of the patient and embedding a Nurse Care manager to work directly with patients and assist in managing chronic conditions.”BMC’s PCMH pilot has been a successful program and has set a new standard for delivering care at BMC. The clinic is moving toward further refining clinic process changes to support a robust PCMH environment, increasing patient education and disease management programs, expanding the care management aspect of the program and increased internal and external education of the program and its benefits to Physicians, staff and payers.


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