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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at The Nebraska Medical Center. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Spring | Summer 2011

A Home for Health

A patient-centered Medical Home is not a building, house, hospital or home healthcare service, but rather it is an approach to providing comprehensive primary care.

Donald Darst, MD
Donald Darst, MD, at Midwest Regional Health Services

The patient-centered Medical Home is focused around teamwork, communication, quality care, chronic disease management and prevention. A primary care team works in partnership with the patient and family to assure that medical and non-medical needs are met, including not only the patient’s immediate needs but preventive care as well. Instead of having the patient’s healthcare records spread among various physician offices, the office of the primary care doctor becomes the central home for all healthcare records and the main access point to all of the patient’s healthcare needs.

It’s what patients think their healthcare provider should be doing for them, but the current healthcare system isn’t well designed to meet those expectations,” says Thomas Tape, MD, chief of General Internal Medicine at the University of Nebraska Medical Center (UNMC).

“In the current system, physicians are seeing more and more patients in order to make a living,” says Andrew Vasey, MD, an internal medicine specialist who introduced the Medical Home model at the UNMC Physicians Midtown Clinic in 2008. “The Medical Home takes the focus away from seeing more patients to focusing on taking better care of the patients we have.”

The UNMC Physicians Midtown Clinic includes nurse coordinators, social workers, diabetes educators, a psychologist, RNs, LPNs, an X-ray technician and a part-time pharmacist and pharmacy resident. “Using a team approach to care frees up some of the doctor’s time so that he or she can spend more time talking to the patient and providing education,” says Dr. Vasey. “Patients don’t feel like they are being rushed in and out.”

“In the Medical Home model, we track patients’ histories closely. We talk to them about screenings, disease prevention and health risks.”
Donald Darst, MD

Midwest Regional Health Services (MRHS) is another clinic that has adopted the Medical Home model. “The Medical Home model allows us to create medical offices that are more personal, more efficient and more proactive in treating patients,” says Donald Darst, MD, internal medicine specialist and founder of MRHS.

“Oftentimes, doctors have time to address only the issues the patient presents when he or she comes to the office,” says Dr. Darst. “Because patients don’t typically come to the office for preventive care, it’s our job to make sure this part of their health is not forgotten. In the Medical Home model, we track patients’ histories closely. We talk to them about screenings, disease prevention and health risks like LDL cholesterol, blood pressure, smoking and diabetes.”

John Langenegger
With Dr. Darst's guidance, John Langenegger's health
is improving and he may soon be able to return
to his career of painting and restoring cars.

The focus on more personal and integrated care is just what Omahan John Langenegger needed. Langenegger’s health was spiraling out of control until he found Dr. Darst and his staff at MRHS.

Diagnosed with Type 1 diabetes when he was a baby, Langenegger began experiencing complications after graduating from high school. His problems gradually multiplied over the next 15 years.

Before handing his care over to Dr. Darst, Langenegger had been seeing a variety of specialists for a variety of problems. He felt lost in the system. Visits to physicians were erratic and he didn’t have a clear plan of action. When Langenegger decided to put his health in Dr. Darst’s hands, he was in excruciating pain. His legs ached, his entire body was swollen, his kidneys were failing, his blood pressure was soaring, his diabetes was out of control and he had developed diabetic retinopathy.

“Dr. Darst said he would help me if I came in to see him every week,” says Langenegger. “He turned everything around for me. I used to be in the hospital every other month. He’s helped me get my diabetes under control and my overall health is improving. It’s been a dramatic change for me.”

Langenegger says Dr. Darst and his team took the time to sit down and educate him about his problems in language he could understand and then laid out a game plan for him to follow. He now understands his medical conditions and what he has to do to manage them. “When I come into the office, everyone knows me and they make me feel very comfortable,” he says. “I’m not afraid to ask questions anymore. Dr. Darst honestly cares about you. I can see that in everyone on his staff, too.”

Langenegger hopes that getting his health back will also help him regain his independence. Multiple health problems and missed workdays led to the loss of his job several years ago. He hasn’t been able to hold a full-time job since. But things are finally looking up. His ultimate goal is to return to his career of painting and restoring cars.

Langenegger’s health has improved greatly, says Dr. Darst. “His blood sugar has improved and so has his blood pressure,” he says. “His neuropathy has been brought under control and there are no irreversible insults to his eyes. He’s reliably taking his medications and once his eyes settle down, he’ll be back to painting.”

Dr. Darst attributes the turnaround to the fact that he and his staff were willing to listen. “We took his beliefs into account in planning his care,” he says. “Where he had misconceptions, we re-educated him rather than disparaging his knowledge. We proved to him that we were his advocate and were reliably available. Once all of these steps had been taken, he began working harder on compliance. He now has hope instead of denial and motivation has replaced despair.”

The Medical Home concept was initially tested more than 10 years ago in North Carolina with positive results. Accelerated by healthcare reform, the concept has been picking up momentum at primary care clinics throughout the country as a promising alternative to reducing healthcare costs and improving the delivery of care.

Andrew Vasey, MD, at the UNMC Physicians Midtown Clinic

Medical staff at the MRHS and UNMC Physicians Midtown Clinic say patients are already realizing the benefits of the Medical Home concept. One of the initiatives addressed by the Midtown Clinic has been the reduction of 30-day readmissions and repeat emergency room visits through education. Before discharge, a member of the healthcare team reviews with the patient a Patient Education Discharge Form that outlines instructions in easy-to-understand language. The results have been promising. Readmission rates dropped to 10 percent compared to 23 percent for individuals who didn’t get the extra education. Also, 90 percent of patients who received the form returned for their follow-up visit to the clinic.

These were significant results, notes Dr. Vasey. Because the clinic serves a traditionally underserved population, patients who miss follow-up appointments may not be able to navigate the current healthcare system and may end up in the hospital or ER, he says.

Another initiative implemented by the clinic includes a focus on diabetes management. The staff identified individuals who weren’t managing their diabetes well. They then developed free education classes to help give these individuals the tools they needed to make healthy changes in their lives. The classes are held once a month and are attended by physicians, certified diabetes educators, pharmacists and dietitians. A nurse coordinator also provides one-on-one education with many of the diabetic patients. Dr. Vasey says the clinic has seen phenomenal results with helping patients manage their blood sugars.

“The Medical Home takes the focus away from seeing more patients to focusing on taking care of the patients we have.”
Andrew Vasey, MD

By improving patients’ health through education and proactive care, Dr. Vasey says the clinic can reduce costs. This then will allow clinics to develop additional disease- management programs in areas such as heart failure, asthma and COPD.

“This is definitely the leading model on how to improve primary care,” says Dr. Vasey.

MRHS has tracked similar improvements in patient care. Two years ago, the MRHS clinic implemented an electronic health database that allows them to track and measure their patients’ health as a group, identify health deficiencies and focus on strategies to restore health in a more focused way. “We were able to identify each patient who was short of the goals we set for disease management and then addressed these with a plan customized for each of them,” says Dr. Darst.

Before implementing the system, Dr. Darst’s office mirrored the national trend of 40 percent for the average number of women completing mammogram screenings. Today, patients in his office average 62 percent. Colonoscopy screenings have also improved. Two years ago, the rate of colonoscopies for his patients was 30.7 percent, still much higher than the national average of 7 percent. But Dr. Darst knew they could do better. Today, those numbers are up to 50.29 percent.

The clinic has also seen a dramatic improvement in the health of its diabetics. To date, 80 percent of the clinic’s patients have reached their compliance blood sugar level goals. Two areas that have lagged behind are diabetic foot exams and eye exams. In response, MRHS sponsors a Diabetes Day every six months, which allows patients to see a variety of specialists in a short amount of time.

“Our early success has opened the doors to all sorts of additional ways we can help patients,” says Dr. Darst. “In the end, the patients are the winners,” says Dr. Darst. “They will be able to get to see their doctor when they need to and we will be putting a greater emphasis on prevention to keep them healthy and to prevent little problems from becoming big ones.

“Having the knowledge that we can do a better job taking care of people than we do now — this is a new paradigm of thinking about patient care that is very exciting.”

Previous article in the Spring | Summer 2011 issue of One Thousand And One:
Charting a Familiar Course