By Jill Nagy
The future of medical care delivery is taking shape in the Adirondack North Country. A consortium of health care providers under the umbrella of the Adirondack Health Institute aims to give every patient a “medical home” with a primary care physician, to focus on preventative care, to assure that at-risk patients get the care they need, and to streamline record keeping.
The so-called Adirondack Medical Home Pilot rewards primary care physicians for spending extra time with patients and coordinating their care. Two years in development, a shared medical data base will soon be online; in the meantime, providers have switched from paper to electronic record keeping.
Bob Crawley, director of medical home initiatives, refers to the “Triple Aim”: to improve patient outcomes, to lower costs, and to improve the patients’ experience.
Initial plans for the change were made at a 2006 “summit meeting” of area providers and payers and government health officials in response to what Crawley calls a “wake-up call,” when the shortage of primary care providers in the North Country became critical. In one year, six physicians left the already medically underserved area.
Cathy Homkey, CEO of the Adirondack Health Institute (AHI), who was at the meeting, recalls that two issues were paramount: the need to recruit and retain more health care providers and the need to improve the quality of patient care. One outcome was the creation of AHI, a consortium of Adirondack Medical Center; Community Providers, Inc., (the parent of Champlain Valley Physicians Hospital); and Hudson Headwaters Health Network.
The Medical Home Pilot was officially launched in 2010.
In Homkey’s view, the challenges of providing medical care in a rural area had morphed by 2006 into a health care crisis. A regional approach made sense, she said, given the sparse population of the area. AHI operates in Clinton, Essex, Franklin, Fulton, Hamilton, northern Saratoga, Warren and Washington Counties. It provides medical homes for between 120,000 and 200,000 patients through a network of 200 providers (physicians, physician assistants, and nurse practitioners) in 41 medical practices. (About 120,000 patients are directly involved in the project; an additional 80,000 or so receive health management services, although they are not officially members of the pilot program.) AHI can implement programs on a regional basis, convoke providers to deal with specific issues, and undertake community health care planning, according to Homkey.
Physicians receive a bonus of $7 per month for each patient for whom they are responsible. That is in addition to the usual fee-for-services payments. “The bonus is helpful,” Crawley said, “but it certainly doesn’t cover the full cost of what the physician does.” In return, they are expected to more actively monitor patients and assure that they receive the care, particularly preventative care, that they need. The aim is to reduce costly emergency room visits and hospital re-admissions while improving patients’ overall health.
A key part of the reform was the introduction of electronic record keeping, substituting laptop computers for paper files. For many physicians, “this was a very difficult process,” according to Crawley. There was a “spectrum of acceptance” on the part of physicians, he recalled, but they all realized the need. “The learning experience is still ongoing,” he said.
The next step is to get the data bases online so that they can be shared – with the permission of the patient. Eventually, a primary care physician and a specialist to whom he or she refers a patient will be able to read one another’s notes; billing information will go directly to insurers and other payers; prescriptions will go directly to the pharmacist. In addition, it will be possible to analyze the data and determine what is working and what needs improvement. It should be possible to answer such questions as whether a particular approach has reduced the occurrence of childhood obesity, lowered the frequency and severity of asthma attacks, or brought about a reduction in the amount and degree of hypertension.
The “data warehouses” will provide data on effectiveness, Homkey sums up.
Developing the data warehouses has required the coordination of varying data bases and incompatible computer systems. The work began two years ago and is almost completed. The Health Exchange of New York (HIXNY) is involved in the creation of the warehouses. A $7 million New York State grant under the HEAL New York initiative helps defray the cost of implementing new health care technology.
Results of the changes are still preliminary and anecdotal, according to both Homkey and Crawley. Both look forward to combing through the data warehouses when they are ready. In the meantime, according to Crawley, “We have seen emergency room admissions and inpatient hospital readmissions start to decline at some facilities.” “If we can begin to bend the cost curve, providers can share in that,” Crawley said. At the same time, the constituents of AHI have been recruiting physicians, with some success.
A parallel effort focuses on the needs of Medicaid patients. Its aim is early intervention with patients with chronic medical or mental health issues. Again, the aim is preventative care and reduction of hospital and emergency room visits. Providers are encouraged to be proactive in reaching those patients. In addition, there is help for patients who are faced with such barriers as lack of adequate transportation or insufficient English language skills. Patients discharged from a hospital will have a care plan that should reduce the chances of a readmission.
“We want to focus care more effectively where it is needed, so that patients at highest risk get the care they require,” Crawley said.
Much of what is happening in the Adirondack North Country meets requirements of the new federal health care law. “It had already been building before the law was enacted,” Crawley said, “but it certainly got a boost from the law. If the law is repealed, it would not completely derail the effort.”
Homkey sees the North Country as a national leader in providing improved medical care. Crawley agrees and recalls that, when he asked about models to follow, he was told that Adirondack Health is the model others look to.
“Every day’s a new day,” Homkey reflects, “It’s all very exciting.”
Homkey joined the Upper Hudson Primary Care consortium, one of the forerunners of AHI, in 2005. Her background is in finance and grant-writing. As CEO of the Institute, she supervises a staff of 34 employees and an annual budget of $5 million.
In addition to coordinating the Medical Home Pilot program, AHI oversees the Adirondack Rural Health Network, a community health planning coalition; Community Health Advocates, providing free consumer assistance with health insurance and access issues; a program using community-based enrollers to encourage children and adults to enroll in Medicaid, Child Health Plus and other affordable health insurance programs; participation, along with 15 other organizations, in a state-funded network promoting improved perinatal health; administration of the $7 million HEAL NY 10 grant to help develop and use the data warehouses; and a program of free confidential services to victims of sexual assault.
For more information about Adirondack Health Institute, call 761-0300 or visit www.adirondackhealthinstitute.org.