Health Care Innovation in Action

After having a stroke and two heart surgeries, Wesley found daily life overwhelming. Managing 30 medications was just one of many demands that persistent memory problems kept him from meeting. When home care ended, he was left on his own to manage his complex health regimen. Wesley needed support beyond what traditional medical care could provide. Enter the Maine Patient Centered Medical Home (PCMH) Pilot.The Pilot provides technical support and training to primary care practices and Community Care Teams that collectively serve over 600,000 privately insured, MaineCare (Medicaid), and Medicare patients statewide. In addition, the Pilot works in concert with MaineCare’s Health Homes (HH) initiative, which has built off the Pilot’s foundation. The HH initiative works with the PCMH practices plus 100 other primary care practices. The MaineCare HH initiative asks HH practices to provide intensive support and work with patients to improve chronic care and reduce health risks. The overarching goal of both the PCMH Pilot and HH initiative is to help patients regain health and stay healthy by supporting primary care physicians and practice teams to change how they deliver care, while also changing the way they are paid.For Wesley, the Pilot became the beginning of a turnaround. He got connected to one of the Community Care Teams (CCTs), Androscoggin Home Care and Hospice (AHCH), a PCMH innovation that organizes nurses, health educators, social workers and care managers into a home-visiting team that addresses a wide range of barriers to good health. Led by CCT Manager Angela Richards, RN, team members visited Wesley’s home and helped him organize his medications – discovering a dosing error in the process. They enrolled him in a cardiac rehabilitation program, helped him plan meals and grocery shopping, and to develop strategies for managing his memory loss. They also installed an in-home blood pressure monitor that transmits data to Wesley’s care team every day.