"Med Home" Health Care Model Promises Coordinated Care

There's an emerging new way to deliver primary care. It's taking root in Cleveland and across the nation. It's called a "medical home." It promises coordinated, preventative care for patients. Imagine if you had a trained nurse whose job is to be your personal health guide, a care coordinator. Not only could you call them, whenever you feel like it, but they call you. "Care coordinators" call you to see if you have questions after a doctor’s visit. They want to know about any issues you’re having. They talk with all your doctors and specialists, to make sure everyone’s on the same page and that treatments are coordinated. And imagine that this care coordinator is your advocate within the system. This is the promise of a new model of health care, called a “medical home.â€? It’s designed to give you that personal guide, and put all your health care under one umbrella. "And I think the reason that it’s called 'home' is the notion that everyone should have one," says Anne Weiss. She's the senior program officer at the Robert Wood Johnson Foundation, a national philanthropy that’s funded medical home initiatives across the country. "I think one of the most frustrating things I have experienced as a patient, and most all of us have experienced, is the complete absence of coordination. To me the concept of the home is the notion that there is one place that knows where you are, knows everything about you, and is helping you make decisions and staying in touch with you," Weiss says. Minister Kenneth Taylor serves at Mt. Pleasant Baptist Church on Cleveland’s east side. It hasn’t been easy for him to stay healthy. "I been through a lot, with its ups and downs, with this diabetes. I never thought I was going to get on track with it," says Taylor. In 2009, MetroHealth enrolled Taylor and more than 10,000 other Northeast Ohio patients in a medical home pilot program. And the results are promising. Patients in the program had more office visits in the first year, but they had 35 percent fewer hospitalizations and about 7 percent fewer ER visits than similar patients not enrolled. And Metro’s overall costs were lower for patients in the medical home. Dr. Jim Misak is a physician at MetroHealth. He says the program works because it adds a new member to the healthcare team: "The care coordinators really are the secret sauce to this program," says Misak. Care coordinators not only help patients navigate the system; they also keep people from falling through the gaps. They check up on them. They make sure they understand their doctor’s instructions and take their meds. They connect them to services they might need, like mental health or substance abuse. Minister Taylor was a little taken aback when he first got a phone call from his care coordinator. "At first I took it as a little...she was pushy! How dare she call me and tell me, you know?" Geneva Jones laughs. She’s Taylor’s care coordinator. They’ve worked out a good relationship now. "I think he realized the value of the relationship when he was able to call me and say this is happening, should I go to the ER or do you think I should get an appointment or I don’t have this medication, what’s available?" says Jones. The program has paid off for Taylor. He feels better. His diabetes is under control. He trusts his medical team, which is made up of Jones, his care coordinator, his primary care doctor, Kenneth Frisof, and other specialists. Taylor voice tracks as he talks about when he was in a bad spot, Dr. Frisof went to personal lengths to make sure he stayed on track. "I remember coming here and I couldn’t get my insulin one day, and he reached in his pocket and said 'This is not a loan, but go get your insulin.'" These programs are still in the experimental phase and still face a major hurdle: how to pay for it all. Right now, insurance doesn’t cover the services. But as the healt hcare industry tinkers with how best to deliver care, the medical home could end up with a starring role.