Patients’ health dramatically improves in first two years of medical home initiative

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Patients’ health dramatically improves in first two years of medical home initiative

Rochester, NY – Patients involved in one of Rochester’s first medical home projects have dramatically improved their health in the first two years of the program.

Data shows that patients are better managing chronic conditions and more patients are getting cancer screenings. The more than 33,000 patients in the Rochester Medical Home Initiative (RMHI) are on average performing better on certain health measures than 90 percent of the national population with similar health issues.

A medical home is a collaboration between patients, physicians and a team of professionals to better coordinate care, especially for patients with chronic conditions such as diabetes and heart disease.

Excellus BlueCross BlueShield and MVP Health Care are coordinating and paying for the three-year program. The initiative began in the summer of 2009 and includes 21 doctors at seven area practices.
“We learned that if you work collaboratively with clear focus and alignment, you can demonstrate dramatic improvements in health care,” said Martin Lustick, M.D., senior vice president and corporate medical director, Excellus BCBS.
The following are examples of how patients improved their health from September 2009 to July 2011:

  • Reduced bad cholesterol: On July 2011, 75 percent of heart disease patients and about 70 percent of diabetic patients had bad cholesterol (LDL) levels below 100. Fifty percent more patients were at this optimum level in July 2011 compared to September 2009.
  • More cancer screenings: The percentage of eligible patients who had colorectal cancer or breast cancer screenings increased from about 60 percent of patients in September 2009 to about 75 percent of patients in July 2011.
  • Improved blood pressure: About 80 percent of patients with hypertension had blood pressure readings at or below 140/90 in July 2011, compared to 65 percent in September 2009.

The project’s most dramatic improvements came from the redesign of doctor and staff work flows that resulted in more personalized care for patients, said Geoffrey G. Morris M.D., of the medical home at the University of Rochester Medical Center’s Pulsifer Medical Associates practice.
“Instead of only focusing on patients during a regular visit, our team also reaches out to them outside the office to ensure their care is more comprehensive,” he said. “This includes monitoring to know when patients are overdue for colonoscopy, mammogram, blood pressure and cholesterol checks; calling patients at home to provide support with issues such as diabetes care; and greater assistance scheduling tests and consultations so they do not have to navigate the medical maze alone.”
The medical homes at Unity Family Medicine at Chili Center and Unity Family Medicine at St Bernard’s enhanced electronic tools and hired nurse care managers to help patients with chronic conditions better manage their health, said Michael Nazar, M.D., vice-president, primary care and community services at Unity Health System.
“Patients are finally able to control their blood sugar and reach healthy cholesterol levels thanks to the extra resources and personal attention that comes with being in a medical home,” he said.
Many patients at the medical home at the Lifetime Health Medical Group’s Perinton Health Center have also improved their health, exceeding many local, state and national averages.

“Patients are more engaged in their health care and tell us that they appreciate the accessibility and open communication with their care team,” said Mark Cohen, M.D., of the Perinton Health Center.

Going forward
“Our medical home project has served as a catalyst for other medical homes in the area,” said Stephen H. Cohen, M.D., vice president of medical affairs, MVP Health Care. “Whereas few practices operated as medical homes when the project first started, many more doctors have since embraced this concept.”
The University of Rochester Medical Center, Unity Health and Lifetime Health Medical Group, for example, have since turned all of their primary care practices into medical homes. Rochester General Health System is also in the process of converting their primary care practices into medical homes.

The first two years of the medical home project focused heavily on improving patient care, especially for those with chronic conditions. The next step is to decrease patients’ need for certain services, such as reducing hospital readmissions and emergency room visits.
The following primary care physicians are involved in the medical home initiative:

  • Drs. Morris, Ann Shamaskin and David Dobrzynski of Pulsifer Medical Associates, Brighton;
  • Drs. Joseph DiPoala, Jr., Nancy Shedd, Robert Caifano, Robert Thomson, Sara Zaka, and Shelly Kane of Ridgeview Internal Medicine, Irondequoit;
  • Drs. Sheryl Holley, Michael Nazar and Shazia Janmuhammad of Unity Family Medicine at St. Bernard’s, Rochester;
  • Drs. Bill Pum, John Bank, Scott Stratton-Smith and Sue-Ann Novak of Unity Family Medicine at Chili Center, Chili;
  • Dr. William Bayer of Jefferson Family Medicine, Rochester;
  • Dr. Robert Smith of Finger Lakes Family Care, Canandaigua;
  • Drs. Cohen, Harneet Kohli and Catherine McPhee of Perinton Health Center, Perinton.

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