For most at-risk, a bet on primary care

Facing the fact that just 5 percent of the patient population was responsible for nearly half of its spending, one health organization has tried some fairly radical changes.

In Utah, Intermountain Healthcare decided to address the problem with primary care in an attempt to keep these most vulnerable patients from falling through the cracks.

Intermountain leaders knew that primary care doctors were up against a universal influx in patient volume and could not set aside enough time and attention to treat the multiple chronic conditions – physical, social and psychological – presented by this most at-risk group. And hospitals were unable to offer these patients personalized, cost-efficient care.

This is not a challenge unique to Salt Lake City, of course.

"We need to acknowledge that most of us don’t spend our lives sitting in a doctor’s office. Most of us spend our lives at home in our communities," said Wendy Wolf, MD, CEO of the Maine Health Access Foundation. "And when people leave the hospital, when they leave the doctor’s office, they have to go home and figure out, ‘How the heck do I do what they just told me I need to do.’”

All the while, readmissions have been racking up alongside costs across the industry, and patients often go home frustrated.

At the behest of affected patients and providers alike, Intermountain created a Personalized Care Clinic, an initiative already starting to show positive outcomes, according to Tim Johnson, MD, medical director of the Intermountain Medical Group, and David Henricksen, regional assistant operations officer of Intermountain Health.

The PCC has the look of a patient-centered medical home, Johnson explained, but the services it offers for a specific patient demographic facing complex, ongoing medical issues is what sets it apart.