How Mercy Health Is Improving Patient and Population Health

Nurturing the Patient Centered Medical Home

By leveraging care coordination technology, we can focus on raising up the health of our entire community versus just working with one patient at a time. It gives us an opportunity to take some of the stress off both patients and care coordinators by replacing some of the in-person follow-ups with electronic communications.

Personal health devices, electronic communications and advanced health technology tools now make it possible for patients to take an active a role in their own health at home. In this way, the “patient-centered medical home” has taken on new meaning. By reaching patients at a population level, who are overdue for a visit or testing, we’re able to take the patient relationship to an entirely new level.

The Agency for Healthcare Research & Quality (AHRQ) defines the primary care medical home as one that provides primary health care that is relationship-based with an orientation toward the whole person. Decision-makers have abundant opportunities to promote patient involvement and to test new and innovative strategies for making healthcare more patient-centered.

Providers and staff like this functionality because there’s not enough time in the day to accomplish all they are tasked with. Right now, between Meaningful Use regulations, ACOs, quality measures, etc., they are asked to do more and more during visits with patients. All are tasks we want to do, but they each take significant time. What used to be a 10-minute visit is now a 30-minute visit and suddenly there’s not enough time in the day to see all the patients who are sick. That’s where coordinated care can help.

Within the first quarter of implementing our focus on care coordination, we’ve made tremendous progress. For instance, we’ve seen a 66 percent increase (4,685 patients) in the number of patients in care coordination from January 1 to May 30, 2014. Admissions per 1000 (annualized) for patients in care coordination for more than six months has decreased by 24.1 percent; ER visits per 1,000 patients (annualized), by 27.6 percent; and inpatient days per 1,000 patients (annualized) by 24.8 percent.