Vanguard Medical Group, in northern N.J., is in year three of its transformation into a patient-centered medical home. Below are three challenges that Vanguard has addressed over the last year. 

Improving coordination with hospitals. "We spent 18 months working with our two local hospitals to get them to identify our patients who are in the hospital and send us a daily census list," says Thomas McCarrick, MD, primary care physician. "The hospitals had not been capturing who the primary care physician was, and the facilities didn't have mechanisms to send us this information."

Vanguard and the hospitals developed a comprehensive daily census report, which is now sent to Vanguard via secure emails from the two hospitals and uploaded into the practice's electronic health record (EHR). "The daily census is terrific because I can see in real-time which of our patients have been admitted, had an emergency department visit or observation stay," says Janet Duni, RN, MPA, population care coordinator. "I am able to manage their transitions of care sooner."

The hospitals are also working on getting comprehensive patient discharge summaries to Vanguard. "Last year, we were getting discharge summaries on only 30 percent of admissions," says McCarrick. "And only 10 percent of the discharge summaries included a medication summary."

One of the hospitals is now transmitting essential documents-including the emergency department (ED) report, history and physical, consult reports, operative reports, and the discharge summary-directly into Vanguard's EHR. The other local hospital is working to accomplish this as well. "These reports are extremely useful when we follow up with a patient because we have accurate, timely information regarding the hospital stay right in our EHR," says Duni. The primary care physician is aware of new medical developments, and I use the information when doing outreach to handle medication reconciliation, schedule follow-up visits, or coordinate with specialists and home care providers. Transition management becomes much more fluid."

Correcting physician/patient mismatches. One way medical homes help ensure continuity of care is through patient panels, which involves assigning patients to a specific primary care physician and care team.

In creating patient panels, Vanguard ran into a practical problem. After sampling 100 patient charts, Vanguard discovered that patients only had the correct primary care physician listed 50 percent of the time. Most worrisome, half of those mismatched patients had a chronic disease and really needed a regular care team.

"EHRs typically ask for a primary care provider in the demographics table," says McCarrick. "Meaningful use requires this, so the EHR system forces our staff to put in a primary care physician's name when they register a patient. But, typically, patients pick a primary care doctor because they are told to and that physician's name is on their insurance card. But once we put that physician's name into our computer system, we never really went back and updated that information, as needed."

Since that discovery, Vanguard has reinvented the process for updating primary care physicians in its EHR, which helps ensure the practice can adequately track and follow up with chronic care patients. "We've added an alert into our point-of-care tool that asks the staff to confirm with the patient who their primary care provider is," says McCarrick "This is done at every office visit whether it's a well visit or an acute illness."

Improving patient access. Vanguard has always had generous office hours, including early morning, evening, and Saturday appointment times. But the practice is taking a number of steps to improve access even more.

Vanguard is tracking the number of patients who do not receive same-day appointments. "We call that a breach," says McCarrick. "By tracking breaches, we can see when exactly patients have trouble getting appointments-by season, day of the week, or provider."

One thing Vanguard discovered is that patients tend to go to the ED on Sundays and Mondays. "Mondays are the busiest days in primary care practices, so if a patient has a problem on Sunday and can't get an appointment on Monday, he or she will just go to the ED," says McCarrick. 

To help address this problem, Vanguard launched online scheduling: "On the weekends, our patients can make an appointment online for Monday," says McCarrick. "This will guarantee that they have an appointment."

Another significant change: A new "no breach" procedure was put in place for high-risk patients. "Before this was not well defined," says McCarrick. "We hoped that staff would recognize potentially high-risk patients when they called for an appointment. Now staff can check if a patient has been identified as high risk in our EHR, and make sure that patient is dealt with immediately. Those patients need to get in the same-day for an appointment or a provider needs to talk to that patient on the phone that day."

Return to main article:N.J. Medical Home Collaboration Pays Off for Patients, Physicians, and Insurer 



Publication Date: Monday, September 24, 2012