Carilion Clinic Medical Home Improves Chronic Care

Ask Anthony Stavola, M.D., how adopting the patient-centered medical home model has changed the way he practices medicine, and he’ll answer with a personal anecdote. It involves a patient with newly diagnosed type 2 diabetes and a drastically high A1C of 18 percent.

“Ten years ago, if this patient had walked into my office, I would have felt very discouraged,” says Stavola, a family physician employed by Carilion Clinic, a health system based in Roanoke, Va. “I would have thought: ‘I’m going to get backed up now because I’m not going to be able to take care of him in 15 minutes.’ I would have done what I could do, but I would have felt like this is going to be like rolling a stone up a hill.”

This time, his reaction was completely different. Stavola talked to the patient a bit — explained the importance of getting his blood sugar under control and mentioned the likely first steps, including insulin. “I immediately said: ‘I know that’s probably scary to you, but we have some people in this office to help us with this, and I’m going to have you see them before you leave,’” Stavola recounts.

Following that visit, the patient submitted his blood sugar readings weekly through the patient portal, and he worked with the care coordinator on lifestyle changes. At the three-month mark, the patient was doing much better. At six months, his A1C was down to a healthy 6 percent, he’d lost weight, and he and Stavola talked about cutting back his insulin dose.

“Most of the work was not done by me,” Stavola says. “It was done by our care coordinator, my nurse, our pharmacists — they teamed up and were able to help him move in the right direction. It was uplifting for me and for our staff.”