Medical Homes: The Next Frontier in Medicine?

Among patients with inflammatory bowel diseases (IBD), the top 25% with severe disease account for 80% of healthcare spending, said Miguel Reguerio, MD, in his presentation at the 2019 IAS meeting. His presentation discussed the creation of medical homes for patients with autoimmune diseases as a way to reduce healthcare spending associated with unplanned care.

Medical homes, first developed in the pediatric field and tested in primary care, are fundamental to alternative payment models to promote patient-centered care, according to Dr Reguerio. The medical home includes a specialist as the principle provider and a team of other specialists to treat both the auto-inflammatory disease and comorbidities associated with chronic conditions.

While biologics are associated with the highest healthcare cost for patients with IBD, the second highest is unplanned care. The characteristics that that drive high costs are not necessarily related to the disease, according to Dr Reguerio. Comorbid psychiatric disorders, such as depression, opioids, surgery, minority race, unemployment, and steroids are among the factors associated with higher healthcare spending in patients. A lot of these do not have to do with the treatment of the disease itself, said Dr Reguerio, but with the chronicity of the disease.

Creating a medical home involves a partnership with a health plan, he said. He developed a medical home in Pittsburg, PA, and is forming on in Cleveland. The homes locations were determined based on patient populations, which were primarily centered around major cities. The “secret sauce” of medical homes, said Dr Reguerio, is the mind/body relationship associated with chronic inflammatory diseases.

On his team is a social worker, psychiatrist/psychologist, IBD surgeons, gastroenterologists, nurses and nurse practitioners, and dieticians. “We have individual schedulers,” said Dr Reguerio, who receive motivational training and are an integral part of the team because “they start the narrative.” Patients are asked “what are your top 3 problems” and “what 3 things would you like to get out of your visit today” when scheduling an appointment in order to inform the treatment plan for their visit. Dr Reguerio showed a sample of the form with these questions a patient filled out that listed psychosocial issues as her main reason for the visit. Patients are not always coming in due to their illness, he said, and the use of these questions help determine who the patient spends more time with, in this case the psychiatrist or psychologist.

Team meetings are held prior to seeing patients and follow-ups, which include all staff members, said Dr Reguerio. Follow ups are conduct using phones or video calls to bring care to the patients. Questionnaires and patient stake holders are used to improve the medical home’s missions and drive patient-centered care.

We did a study, said Dr Reguerio, that showed some improvement in unplanned care costs among high utilizers with IBD. However, Medicaid, steroids, opiates, and prior therapy still affected patients’ use of emergency department visits.

Unlike Centers of Excellence, which are situated around specialists, medical homes are collaborative and patient-centered to address all aspects of immune-mediated inflammatory diseases. The medical home in Cleveland is attempting to reach more patients across the state through networking and partnerships with primary care providers to improve patient outcomes and ensure all patients receive quality care.

Reference

Reguerio M. The IBD medical home. Presented at: 2019 Interdisciplinary Autoimmune Summit; April 5-7, 2019; Chicago, IL.