From Suburban Dallas to Rural Kansas

FPs Succeed in Creating Medical Home for Patients

February 17, 2009 03:50 pm Sheri Porter

Terry Hanlon is a 60-year-old man who, by his own account, hadn't had a health physical since his stint in the army three decades ago and had never heard of the patient-centered medical home, or PCMH. Then, about a year ago, Hanlon stumbled onto the medical home model when he made an appointment with Christopher Crow, M.D., M.B.A., a family physician and the managing partner of Village Health Partners, a mid-sized physician practice located in Plano, Texas, an upscale suburb north of Dallas.

Now, a year later, Hanlon is hooked on health care. The same man who skillfully avoided doctors for years has returned to Crow's medical complex more than half a dozen times for follow-up care, including wellness and preventive services.

What keeps him coming back? Convenience, accessibility and advanced technology, all components of the PCMH.

"I'm sold on the package deal of what the Village Partners offer," says Hanlon. "I've been to physical therapy and to four different facilities within the facility. I feel a much bigger incentive to pursue a healthier lifestyle because Dr. Crow is there to monitor things and give me good feedback."

Vision Becomes Reality

Village Health Partners is not a multispecialty practice; rather, it's a family medicine practice that anchors Legacy Medical Village, a well-rounded assortment of subspecialists and health care services housed under one very large roof.

The 37-year-old Crow went into private practice in 2001, expanded his practice in 2004, and in 2007, created the village as his vision of perfect patient accessibility.

Eight physicians and two mid-level providers serve as the foundation of what Crow calls a health pyramid. The middle is filled with subspecialists that Crow knows patients need frequently, such as a cardiologist, a urologist and an ophthalmologist. The village also gives patients easy access to services, such as lab work, X-rays, physical therapy and pain management. On Jan. 1, a new wellness and weight loss center opened its doors.

"We've put primary care back in control," says Crow, because "95 percent of a patient's health care needs can be met right here."

For example, one patient who had a 9 a.m. appointment is on her way home before noon with a number of routine health care services under her belt. She had lab work done; received a mammogram and a bone density scan; and scheduled a colonoscopy. The ophthalmologist downstairs even made time for her yearly diabetes eye exam in his morning schedule.

Giving time back to the patient "is our value proposition," says Crow. The proximity of health care services, the electronic communication between all parties, and everyone's commitment to patient satisfaction means that this patient "didn't have to schedule four different visits on four different days."

Practice Pulls the Pieces Together

How do Crow and his colleagues manage the logistics of a practice that saw nearly 40,000 patient visits in 2008 and that refills 10,000 prescriptions monthly? They do it by streamlining workflow and procedures, and by putting the practice's robust electronic health record, or EHR, system through its paces.

With his laptop computer within reach and a five-minute break between patients, Crow reviews five patients' lab reports. "It's a complete paradigm shift," he says, adding that patients get lab results in 24 hours. "It becomes a question of how to do common things most efficiently." Crow's mantra is "running your practice like a business for the betterment of your patients."

The importance of the EHR can't be downplayed, says Crow. The practice has remote access; electronic prescribing; electronic transmission of lab results and X-rays; and electronic data and order entry.

Patients in this PCMH also enjoy a bevy of online services, including their own patient portals, prescription refills, appointment scheduling and bill payment. For a yearly fee of $50 per patient or $100 per family, patients can even get 24-hour e-mail access to their physician, an option about 10 percent of patients have chosen.

Crow and his partners built the practice -- the largest medical group in the wealthiest county in Texas -- around what patient surveys said patients wanted -- namely, access, convenience and quality.

That means extended weekday and weekend hours and same-day service for urgent needs. The average wait time is five to 10 minutes. According to the practice managers, retail health clinics have a healthy foothold in the Dallas metro area, but they have had zero impact on Village Health Partners.

Rural America Presents Challenges

Meanwhile, 300 miles to the northeast in Neodesha, Kan., FP DeAnna Vaughn, M.D., runs her steadily growing practice according to this philosophy: "Adapt, adjust and overcome."

Although the town reported fewer than 3,000 residents in the 2000 census, a steady stream of patients from nearly a dozen surrounding counties keep Vaughn and partners FP Amy Cunningham, D.O., and Tawneya Madl, A.R.N.P., plenty busy.

Nonetheless, Vaughn's practice, SEK Primary Care Associates, faces daunting challenges as a small practice in rural Kansas. The team works hard to be a medical home for the nearly 2,000 patients who walk through the door each year.

Vaughn has a ready list of the disadvantages her practice faces, including

  • a patient population that includes a good number of people with limited financial resources;
  • limited access to subspecialists and ancillary professional services, such as social workers, dietitians and support groups;
  • the logistical nightmare that comes with tracking and coordinating reports and lab work from five hospitals that are miles apart and not electronically linked;
  • health information technology support that is hard to come by; and
  • the reality that small practices with limited financial resources have no "pull" with vendors and don't get the price breaks that large groups enjoy.

For example, Vaughn has been waiting for months for an upgrade to the 8.0 version of her EHR software. She figures she's at the bottom of the list, behind larger practices with more purchasing power. (Editor's note: Vaughn recently notified AAFP News Now that the 8.0 update had arrived and the practice was in the process of completing additional staff training.) The irony, says Vaughn, is that smaller communities like hers need the full functionality of an EHR. "We have patients who are very complicated who can't travel," and nonexistent transportation services, she says.

Still, Vaughn and Cunningham know their practice is the foundation of their patients' health care. "One of the main jobs of family medicine is being the 'captain of the ship,'" says Cunningham. "We have all the pieces to the patient's health care puzzle and can facilitate other care because we know the whole patient," she adds.

The job is harder to pull off in a rural setting, but Vaughn and Cunningham have learned to "pick and choose" the medical home concepts that the practice can realistically implement.

Practices Share Winning Strategies

For all of their differences, the sprawling practice in Plano and its counterpart nestled in Neodesha have much in common.

Quality is important. Vaughn participates in CMS' Physician Quality Reporting Initiative and takes great pride in the practice's aggressive diabetes management program. Crow's practice attained recognition in 2005 from the National Committee for Quality Assurance, or NCQA, for its care of patients with diabetes.

Both practices want to get NCQA's PCMH recognition, available from its Physician Practice Connections -- Patient-Centered Medical Home program, even though neither will see any immediate financial payback for doing so. Crow is certain that 2009 will bring him NCQA's Level 3 recognition -- the highest possible. Vaughn is confident that when she is able to implement patient registries, she'll qualify for a Level 2 recognition.

Both practices also target wellness and prevention and pound home patient responsibility. Similar encouraging phrases pepper patient encounters in Texas and Kansas. "We're here to support you." "You have to make the right decisions." "We're going over these lab results together."

Change is a word neither physician takes lightly. "It's important that we strive for continuous improvement," says Vaughn.

As for Crow, if a team member were to say, "This is how it's always been done," his response would be, "Why, when evidence-wise and technology-wise, there might be a better way?"

Crow's not ready to stop innovating yet. "Although we are successful by every stretch of the imagination right now, we certainly have lists and lists of things we'd like do to in the future so that we can continue to compete and do well and take care of patients," he says.