A Michigan pilot to bring primary care to the home for patients living with advanced chronic illness will now spread across the state. Priority Health, a Michigan-based nonprofit health plan, tested the concept last year with Spectrum Health Medical Group for 90 of its patients.
Among Spectrum’s pilot patients, emergency room and hospital inpatient visits have dropped 47 percent, said Priority Health in a recent news release. Spectrum Health Medical Group is part of an integrated system in western Michigan.
“By working as a system, we can …change the model of care for those with complex chronic conditions, ultimately improving their quality of life,” said Kenneth Fawcett Jr., MD, interim president of Spectrum Health Medical Group, in the release.
Spectrum Helth has home healthcare and skilled nursing facilities, as well as home physical therapy services, all of which are critical to the model, said Jay LaBine, MD, Priority Health medical director. "All entities are working toward the same goal, changing the model of care delivery to better service patients with multiple chronic conditions," he said in emailed comments.
Currently, the program is financed as a pilot program through Priority Health's integrated delivery system, providing reimbursement for infrastructure and billable services. "At the end of the pilot, we will reconcile to assure our delivery system is kept whole, and they have not lost money on the program," LaBine said. "We anticipate that as we gain more experience with this program, we will build a shared savings model."
Each patient in the home-based primary care program receives care from a team that includes a physician, nurse practitioner, registered nurse case manager and social worker. Patients also receive routine and preventive care through the program.
Initially, a nurse practitioner or nurse case manager conducts a health assessment, creates a care plan, which is reviewed by a physician, who then coordinates home visits based upon the patient's needs.
Patients who have advanced chronic conditions have difficulty traveling to a physician’s office for routine care. The point is to “take the concept of a doctor’s office and broaden its reach to literally meet patients who need support most, where they need it most—in their home,” LaBine said.
Patients need to be referred by their primary care physician and meet other qualifications to be eligible. Once in the program, the patient receives around-the-clock medical support; a plan of care that evolves with the patient’s needs; a nurse care manager to monitor the patient; and occupational, physical, respiratory and speech therapy.
The program also offers patients education about their medications, tele-monitoring procedures and preparations in case of a health emergency.