The care coordination resulted in improved outcomes in areas such as lowering blood pressure, controlling cholesterol, and educating asthma sufferers. Specifically, the blood pressure levels at lower than 140/90 showed a 45% improvement, from 57% of people with acceptable blood pressure in 2008 to 83% in 2012.
High blood pressure is linked to an increase risk of heart attack and stroke, and has been defined as any number higher than 140/90. The test for LDL cholesterol is used to predict the risk for developing heart disease. The elevated levels of LDL cholesterol can indicate a risk for heart disease, with an optimal reading of less than 100 for those at risk.
According to the Chronic Care Initiative, the tests showed a 60% improvement from 2008, when there were 35% in the desired range, to 2012, when 56% had acceptable cholesterol levels.
Asthma is always a concern. The chronic lung disease can be life threatening, but it is usually manageable so people can live a normal, healthy life. The Chronic Care Initiative established an "asthma action plan" as part of its medical home program to help patients self-manage this condition. There has been considerable impact, says Snyder.
While 53% of patients had their asthma under control in 2008, that increased to 76% in 2012. In effect, physicians use the tool to help asthma patients evaluate their own conditions for better care.
For instance, patients are asked to check their peak flow—a measurement of how fast they can exhale—at least daily, and more often when asthma symptoms appear. If the patient has no symptoms and the peak flow is in the expected range, then the patient is in the green zone and simply takes his or her maintenance medications. Patients may enter the yellow zone, in which some medications are needed. If a patient has a lot of trouble breathing—or is in the red zone—then it is time to call 911.
The medical home model and its coordination of care proved to be a successful plan to control healthcare costs compared to other methods the insurer tried, Snyder says. "Over the years, we implemented disease management plans and outsourced them to other companies in an attempt to get better control over chronic conditions. That didn't work well."
One of the biggest flaws in those disease management plans, as Snyder sees it, was the insurer's failure to have providers—not just the insurer—involved from the beginning of care, from the first phone call to follow-up contacts. "Patient education doesn't really work when a nurse is sitting in a different state, calling on behalf of an insurance company," Snyder says. What does work is when the patient gets a call from a medical professional that he or she has personally met. "That patient feels guilty for not listening to the doctor or nurse."
Success key No.2: Accountable care organizations
Large and small healthcare organizations are teaming up with physician groups to initiate the medical home model within ACOs, with patient engagement as a top priority to manage chronic diseases.
In 2012, Summa Health Network—the Akron, Ohio–based physician hospital organization affiliated with Summa Health System Hospitals—launched NewHealth Collaborative, a medical home within its ACO. NewHealth incorporates the practices of 203 physicians who care for 44,000 patients, says James Dom Dera, MD, FAAFP, medical director of the NewHealth Collaborative. For Summa, as with many other medical homes, a primary focus is on diabetes, a chronic disease characterized by a broad range of metabolic abnormalities.
"Diabetes is one of our top priorities, because it's our No. 1 diagnosis, impacting so many people," says Dom Dera, who also is a physician with the Ohio Family Practice Centers Inc. in Fairlawn, which is part of the ACO. "We said, 'Let's try to find a way under the auspices of the accountable care organization to see if we can start to transform patient care."