You don't have to do it all: Connecting patients with community resources
When our practice was first introduced to the medical home concept, we were overwhelmed by the amount of services we should be providing to our patients. For example, the medical home model emphasizes patient self management, especially for chronic diseases. That means that patients with diabetes need guidance on diet, exercise, medications, injections and lifestyle changes. While we thought we were doing a pretty good job at this, fitting all this guidance into four 15-minute visits per year was probably not enough. How could we provide this care better – without adding FTEs? The answer became linking patients to existing resources in the community to supplement our in-office care.
Treating your patients as part of a larger population or community was an important part of the National Demonstration Project (NDP). Practices in the NDP soon discovered that they could not by themselves provide all the services implicit in a medical home. Financial, time and geographic barriers prohibited the provision of all services to all patients.
Dietary counseling, pharmaceutical services and therapy are some of the elements that may best be provided by facilities outside the medical home office. Costs of providing these services can be defrayed if practices tap outside sources to provide these services. We have a diabetic educator in our larger health system who does a very good job educating patients about their diet. The problem is that there is only one of her, and we have a LOT of diabetics. Furthermore, patients have to travel 20 minutes and navigate a large medical complex to get to her. Compliance with recommendations and follow-up suffers. But then we became aware that one of our favorite local pharmacists had become a certified diabetic educator, so we began having patients see him for diet and exercise advice. He also threw in medication advice. Since the pharmacy is in our town, patient compliance and follow-up was terrific.
If your practice does not have diabetic educators nearby, there are other resources. Visit http://www.diabetes.org/ for a plethora of free patient education ideas and support for professionals.
Our practice also utilizes home health to supplement our services to patients, and we have had some very good results reducing hospitalization rates for patients with CHF by educating them on diet and the importance of daily weights, with standing instructions for diuretic dosing based solely on daily weight changes. Many insurance companies will give patients a free scale. Recently, Optima Health has been offering scales and a daily phone consultation for CHF patients to assist with managing their fluid status and to recognize, report and treat early signs of an exacerbation. Now, we all know it would be terrific if payers would pay primary care physicians and their offices to provide such intensive management right from the office, but this is not yet a reality in most markets. Taking advantage of other resources can provide patients with much-needed services at no additional cost to the practice.
Another area where community resources are useful is with dementia. This devastating group of illnesses is very time and labor intensive for the family physician's practice. Many communities have Alzheimer’s programs, such as the one in our county: http://www.alzalliance.org. The Alliance offers a wealth of services to help both patients and their families cope with this devastating illness. I have referred several patients to this group and have been thanked for doing so. Helping patients find other individuals in the community who are dealing with similar health issues is very valuable for their overall care. Having a reliable resource to simply answer questions can save time and money in the care of individuals with dementia.
Hopefully these examples will help you explore ways you can connect patients with community resources. This networking approach shifts the cost of complicated care off the practice and encourages the patient to take more responsibility for self-management, core goals of care in the patient-centered medical home.