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Riverside County Working on Public Health Medical Home

RIVERSIDE — The Riverside County Public Health Department has begun the planning process for implementing a patient-centered medical home at its primary care clinics.

The medical home is expected to give physicians more time to focus on their patients and provide a smoother system for patients to access the services they need. The patient-centered medical home concept is a team-based approach with the primary care provider serving as the team leader coordinating care.

“The system currently is extremely frustrating to both providers and patients,” said Laura Robert, chief of medical services for the county’s department of public health. “If we can do primary care right, we can save money and keep people healthier.”

Health officials and experts say developing medical homes is one of several steps public and private providers are taking in anticipation of transformational changes to health care delivery as a result of health care reform.

A number of Southern California counties already have begun medical home projects. In Ventura County, Medi-Cal beneficiaries are reportedly scheduled to be assigned this year to a medical home through the Gold Coast Health Plan. In Los Angeles County, 11 community clinics will be transformed into patient-centered medical homes through L.A. Care Health Plan.

Medical homes typically are credited with better coordination of care and the prevention of chronic illness. Riverside County’s medical home is expected to help reduce the number of patients who fall through the cracks and assist with lowering the rates of preventable diseases. The county is currently grappling with high rates of obesity and diabetes.

Looking Ahead to 2014

Health department officials are looking ahead to 2014, when major provisions of health care reform will take effect. They will need to have plans in place to deal with the addition of new, previously uninsured patients. Implementing a medical home and electronic health records may help the county cope with an unprecedented number of enrollees.

Nearly 550,000 uninsured live in Riverside County, according to a 2010 study by the UCLA Center for Health Policy Research.

“There are a lot of people out there, and I don’t know what they’re doing for health care,” Robert said. “We’re going to have a large influx of patients. There will be people clamoring for services.”

The county public health department, which was affected by budget cuts in 2010, is the only source of health care services for many of the county’s low-income residents. The department projects 129,000 visits for this fiscal year, with 68,000 unique patients who rely on the county as their primary care provider, Robert said.  The department is in the process of expanding and is hiring nine new teams, including six doctors, to take on roughly an additional 30,000 patients, she said.

Robert said there will be more to implementing the medical home than just checking off items on a laundry list. The key is to determine patients’ actual needs in order to achieve optimal health, she said.

“The challenge to implementing [a medical home] is to not focus on system design to the detriment of maintaining the focus on patient-centered care,” Robert said.

She added that the county is not looking to duplicate any one system, but will be drawing upon a number of examples of successful health care systems. She expects implementation of the county’s medical home to take approximately two years.

Dolores Green, executive director of the Riverside Medical Association, said in addition to the county public health department, a number of Inland Empire community providers are working toward implementing medical homes.

“They’re not behind the curve; they’re not ahead of the curve,” she said of the public health department. “They are probably in the middle of the curve.”

Early Adoption

One Inland Empire practice that has been ahead of the curve is Redlands Family Practice, which instituted a medical home approach in the early 1980s.

“Everyone keeps telling us we’re unique,” said Sandee Derryberry, executive director of Redlands Family Practice and the physician group PrimeCare of Redlands. “We are simply applying a full customer-service approach. What kind of problems does the patient have? Then let’s figure out how to deal with them.”

Patient anxiety can actually contribute to driving up health care costs, Derryberry said. A patient whose doctor does not spend enough time addressing all of that patient’s concerns is more likely to make multiple calls and schedule more visits than may be needed, she said.

“There’s a lot to be said for making sure you have the time to answer all of the patient’s questions,” Derryberry said, explaining that having a trusting doctor-patient relationship leads to smoother provision of care down the road.  

The practice also broke from the standard 10-minutes-per-patient doctor visit. Consequently, the practice’s physicians have the luxury of time, particularly in the first early visits with a patient, to do thorough evaluations and get a handle on treatment, which often saves time down the road, she said.

The practice’s system involves making sure that patients have 24/7 access to care so that any time a patient calls in with a question, he or she will always receive the same, consistent information, she said.

Patients know that if they have an urgent problem they will be seen that same day. Doctors take the time to get to know their patients, to set up a treatment plan and go over it with the patient, she said.

“A patient knows they are going to be taken care of when they call here,” Derryberry said.

‘The Right Thing To Do’

Green said that while the concept of medical homes was put to work in the Medicare system many years ago, health care reform has become the driving factor encouraging providers to re-engineer the way they deliver care.

The law provides funding for medical home pilot projects and calls for the Center for Medicare and Medicaid Innovation to experiment with new payment systems, which could include medical homes.

The capitated payment model is not unusual in California, but implementing medical homes is happening more frequently, partly because it results in financial savings for providers.  

In a capitated system, the provider is paid a certain dollar amount per patient whether that patient is seen or not. Providers in the system have an incentive to keep the patient healthy to avoid incurring more costs, Robert said.

While the health reform law does not propose an exact structure for medical homes, it is expected that incentives will be created to reward health care providers for the quality of the care they provide, rather than for the volume of patients that they treat.

Additional financial savings can be realized in a medical home approach through improved efficiency, managing patients better, keeping hospitalization rates and emergency department visits low, and monitoring conditions in a preventive manner, Green said.

Robert, however, believes there’s more driving the adoption of medical homes than just health care reform.

“Doctors have known for years that this is the way to deliver primary care. We’ve all been trying to get there. We’ve been shackled by not having the resources to do it and the idea that doctors don’t do a very good job at uniting and pushing forth an effort,” she said. “The motivation behind it is that it’s the right thing to do, and that it’s the right way to deliver primary care.”