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The Seven “R”s to Transforming a Medical Practice into a Medical Home

October 11, 2013
By Kristina Grifantini

Jennifer Lail, MD
Jennifer Lail, MD

For the last decade, a national movement has begun to shift healthcare into a family-and-patient-centered medical home model. Though the term is a mouthful, the philosophy is about delivering services that truly serve the patient by making healthcare more equitable, accessible, culturally relevant, coordinated, preventative and efficient. This is particularly relevant for patients with special or complex healthcare needs.
 
Several things can support moving toward a medical home: better patient recordkeeping, more targeted referrals and more emphasis on prevention. Not just beneficial for the patient, medical homes can help practitioners deliver their care more effectively and timely, and the emphasis of preventative care eases the burden of healthcare costs in the long run.
 
NICHQ recently spoke with Jennifer Lail, MD, a medical home advocate and the assistant vice-president for chronic care systems at Cincinnati Children’s Hospital, about how she became involved with quality improvement work in medical homes and what practices can start to do to move in that direction.

What made you want to start developing a medical home?


I started to hear about the medical home concept in the early 2000s. Then, I was working in a practice that served 25,000 patients. We knew that we weren’t optimizing our care for kids with more complex issues because we were in a 10-minute visit, treat-one-problem model of care. We would finish a day frustrated that we hadn’t done as well as we should have with someone who had a lot of issues.
 
At the time, I got wind of NICHQ’s medical home learning collaborative for children with special healthcare needs. I worked with partners to develop funding to support our participation. That started the whole thing.

What did you learn from the NICHQ learning collaborative?


In terms of quality improvement, the learning collaborative gave us a sense of perspective by saying you can’t come in and renovate something all at once; you have to do small changes over time for effective quality improvement.
 
From the collaborative, we learned the tools necessary to launch a medical home project. After the collaborative, we became the medical home demonstration project for the state of North Carolina. It became quite clear that the medical home model was financially viable. During and after the collaborative, we built a registry for children with special healthcare needs, developed a care coordinator role, created robust pre-visit planning process, improved referral tracking through our care coordinators and worked on staff self-management skills.

What advice would you give to practices striving to become medical homes?


In my practice we found there are several things you need to have to move toward becoming a medical home. I call them the "Seven R’s."

  1. Relationships: We put that first. Relationships with families, with the community and with other providers are the foundation of being a medical home. For us to be the axle of the wheel around which a child’s complex needs are rotating we had to have those relationships and they had to be strong.
  2. Ready Access: We expanded office hours in evenings, weekends and holidays so the families could get in to see us.
  3. Registry: We developed a patient registry to support care coordination and care visit planning. This helped us with pre-visit planning and understanding who our population was and who needed care.
  4. Records: We realized that measuring care is really hard with paper records so we established an electronic health record system. It allows us to more easily measure if we are serving our patients better.
  5. Resources: We created a database of our resources to make referrals easier. Our providers can look up, for example, a psychologist that would see a child on Medicaid, or a dentist who would see a child with autism.
  6. Reimbursement: We worked very collaboratively with Medicaid and with commercial insurers to document that we were decreasing emergency room visits. We also documented that we were keeping kids healthier by getting their preventative and well services done, which helped convinced insurance companies to get onboard with support the medical home model.
  7. Recruitment: After we developed tools, we shared them across the country to encourage other colleagues to develop their own medical homes. 

I would also suggest practices visit the medical home implementation website (www.medicalhomeinfo.org). It is a great resource for practices transitioning to medical homes.

What is the state of the medical home today?


I am very excited how the medical home model is spreading across the country. The ideas from the first collaborative that NICHQ began in 2002 spread across the US almost like an infectious disease. States have worked with their Title V folks to spread change. It is rare in the pediatric community to not know what a medical home is and I find that tremendously exciting.
 
It will take time for complete adoption of the model. The biggest barrier I perceived is time for transformation. In a busy pediatric practice, walling off time to look at how a system works, evaluate processes, make an aim, and figure out a goal and drivers of the processes all require stepping back from the clinical stuff. However, the conviction that a medical home is the best place for a child to be cared for is growing. I think there are more and more people who are putting the pieces in place.

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