UPMC Health: How the patient-centered medical home model can reduce readmissions

Preventable hospital readmissions cost the U.S. health care system an estimated $25 billion every year, according to a study by PricewaterhouseCooper’s Health Research Institute. A logical first step toward containing health care costs would be in controlling the expenses related to these readmissions.

“The patient-centered medical home is becoming a very effective tool for reducing preventable hospital readmissions,” says Dr. Stephen Perkins, vice president for Medical Affairs at UPMC Health Plan. “The care and attention that patients are provided in the medical home model is compatible with improved quality of care, well-coordinated care and readmission prevention. Coordinating care for patients with complex conditions is essential.”

Smart Business spoke with Perkins about how the patient-centered medical home (PCMH) can be effective in reducing preventable hospital readmissions.

Why is the PCMH concept effective in reducing preventable hospital readmissions?

The PCMH stresses that a personal physician and a personal physician’s staff should proactively and holistically coordinate their patients’ care. Because the model encourages patients to become more engaged in their own care, patients are more prepared before, during and after their hospitalization to understand their condition. This leads to less confusion about their care plan and a better understanding of their self-care once they are sent home from the hospital.

What elements of PCMH make it especially suited to reduce preventable hospital readmissions?

One potential component of a PCMH is the use of practice-based care managers. These care managers — who are often nurses or social workers — can coordinate health services with other providers, manage a patient’s health conditions, connect the patient with community resources, assist patients with managing prescriptions, and help members focus on lifestyle changes including lowering or maintaining weight, decreasing stress, smoking cessation, and identifying safety and fall risks in the home.

Practice-based care managers help serve as the bridge between members and their physicians — before, during and after office visits — as they function as part of the physician’s team, coordinating and assisting in the development of a care plan for members. They support their physician practices and meet with members face-to-face to address knowledge gaps and provide self-management tools.

These care managers also assist physicians in the delivery of continuous, accessible and high-quality patient-oriented population management by identifying stresses placed on patients and caregivers upon discharge from the hospital. They coordinate health services with other providers, and work with patients before and after hospital stays to make sure each patient understands his or her condition and care regimen. Practice-based care managers make direct contact with patients, identify barriers to care and educate patients.

Essentially, the use of practice-based care managers is a way of changing the workflow in the medical community. Historically, the medical community has approached health care in a reactive way; that is, they react to a patient presenting for care, rather than anticipating care needs. Likewise, patients react by seeking episodic care. In order to control costs and improve quality, this paradigm must change to allow the practice team to understand management of their patient population, and yet focus on the specific to identify the needs of individual patients.

What are the benefits to patients in a medical home situation?

Patients receive more coordinated services in a medical home system, which results in less confusion about their care plan. This usually leads to better compliance with the recommended treatment. In addition, they share in the decision-making with the physician and care team. The physician and patient are on a much more parallel track, understanding the patient’s goals, which causes greater patient satisfaction.

Dr. Stephen Perkins is a vice president, Medical Affairs, at UPMC Health Plan. Reach him at (412) 454-7682 or [email protected].

Save the date: Tuesday, Oct. 22, webinar “The Physician’s Role in a Changing Health Care System,” from 11 a.m. to noon. To register, visit the “Webinars” page, or email Lauren Formato at [email protected].

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