UAB Clinic Offers Centralized Care

By Jo Lynn Orr

Stuart Cohen is one of a group of physicians and nurse practitioners who have established a Patient-Centered Medical Home at UAB's Kirklin Clinic. The concept, a key component of health-care reform, is focused on providing coordinated care with an emphasis on patient education.Sometimes a trip through the health-care system can seem like an endurance contest, requiring multiple visits to a range of specialists and other health-care providers in offices all over town. But a unique partnership between primary-care physicians at UAB’s Kirklin Clinic and the UAB School of Nursing aims to change that by replacing the poorly coordinated, episodic, acute-care focused model with a more comprehensive, proactive, team-based approach that engages patients as partners in their own health care.

Six physicians at the clinic’s Internal Medicine-1 practice have joined together to establish a Patient-Centered Medical Home (PCMH). The concept has gained popularity in recent years and is a key component of the health-care reform measures passed by the federal government in 2010. A PCMH coordinates all patient care, including referrals to subspecialties such as cardiology, orthopedics, and rheumatology; following up with patients who have been hospitalized; and providing education on managing chronic diseases.

At UAB’s PCMH, all patient information—including X rays, lab results, and hospital and subspecialist records—is available electronically at the touch of a computer keyboard, which allows all providers access to crucial information.

Nurses and Nuance

Because managing chronic disease is the medical staple of primary-care offices, the Kirklin Clinic medical home staff includes a full-time nurse practitioner and two part-time nurse practitioners who are members of the School of Nursing faculty. “In addition to their advanced nursing education and experience, they have experience in teaching, which augments the medical home’s patient education efforts relating to chronic diseases,” says Stuart Cohen, M.D., who heads up the PCMH group and is medical director of Prime Care Internal Medicine at the Kirklin Clinic.

There’s also a high degree of trust among patients for nurses, who are usually seen as the “first responders” on the front lines of health care, adds Cynthia Selleck, D.S.N, A.R.N.P., associate dean for clinical affairs and partnerships at the School of Nursing, who helped forge the PCMH alliance. “Nurse practitioners are a wonderful resource because they can spend more time with patients to help them manage chronic diseases through proper education about the disease process,” Selleck says. “They also explain the nuances of self-management for patients and family, focus on the importance of diet and exercise on health, and address some of the behavioral aspects of chronic disease—all of which are essential to the proper care of patients.”

Routine Maintenance

Chronic diseases that primary-care providers typically monitor include type-2 diabetes, hypertension, coronary artery disease, congestive heart failure, osteoporosis, COPD (chronic obstructive pulmonary disease), and depression. “If a patient sees me for a routine visit and also has diabetes, hypertension, hyperlipidemia, and osteoporosis, I will try to deal with all of those issues within a visit,” Cohen says. “But I might also have the patient follow up with one of our nurse practitioners, who will take a more proactive approach on chronic-disease management and education and review the patient’s dietary habits and exercise regimen. The nurse practitioner will work with the patient to set goals for things such as exercise, diet, weight loss, and tobacco cessation and then follow up with a telephone call a few weeks down the road to see how things are going.”

Healthy Handoffs

Coordinating transitions of care is another central feature of the medical-home concept. “If one of my patients is admitted to the hospital, I’m automatically notified via e-mail,” Cohen explains. “A designated care manager from our office will then contact the patient and the patient’s family to schedule appropriate follow-up appointments and see that all goes smoothly. When the patient is discharged, the care manager cross-checks medications prescribed in the hospital against prescriptions the patient normally takes to rule out discrepancies. Often when patients are hospitalized, their medications are changed. Then when they’re back home again, they have no idea what medications they’re supposed to take.”

It’s no longer practical for physicians to make house calls, but if there were ever a time when patients could benefit from a home visit, it would be after discharge from the hospital. That’s another area where the partnership with the School of Nursing may provide added value, Selleck says. “We already have nursing students who do community-health rotations and who could visit PCMH patients at home. Incorporating students in the care of patients in a team-based PCMH model is a win-win for everyone—patients, students, and providers alike.”

Better Care for Less?

Patient-centered medical homes “also are of great interest to insurance companies because they are seen as a care approach that might help contain soaring medical costs, particularly those associated with hospital stays,” notes Cohen. UAB’s PCMH is part of two pilot projects: one with UAB’s homegrown insurer, Viva Health, and the other with Blue Cross Blue Shield of Alabama (BCBS). “Both companies are looking at our quality metrics and comparing them to standard practice within the medical community and norms,” Cohen says. "Both Viva and BCBS are looking at where our group was before we embarked on this  journey and where are we now. They want to see if gains were made in quality.” As part of the pilot projects, UAB’s PCMH is receiving additional funds from these insurers, Cohen adds, “and part of the funding we get moving forward will be based on quality.”

Back to the Future

Despite the fact that medical homes are a hot topic in health-care circles, this is really a “back-to-the-future” concept, Cohen points out. “Over time, our health-care environment has become driven by medical subspecialties. One goal of the medical home is to strengthen primary-care practices so they can better serve the population through quality care and act as the central hub for the coordination of care."