Inspiration Leadership Community

Bringing The PCMH HOME

By Kyle Bradford Jones, M.D.

The family physician who recently shared his story about the challenge of finding a patient-centered medical home (PCMH) residency program has now finished residency and joined the faculty at University of Utah, where he spends his clinical time at the Neurobehavior HOME Program, a PCMH for those with developmental disabilities. Here he tells us about his first months in practice.

“I’m worried about Carolyn, one of our patients with diabetes. She is in her mid-20s, and hasn’t been seen for a number of months, even by any of the psych providers. Her diabetes is very poorly controlled and she has no-showed a bunch of visits lately. She no longer has a telephone or an email address, so we can’t get a hold of her easily.”

This was morning rounds at my new job at a patient-centered medical home that cares for patients with developmental disabilities. Rounds are a daily forum for case managers, providers, and other team members to bring up patients that have specific struggles that need to be addressed. Our nurse, Melissa, who monitors our panel of patients with diabetes among other responsibilities, was presenting Carolyn (not her real name), a patient that had seemingly fallen off the grid.
“She has had worsening pain in her lower legs as of the last time I spoke with her, and she was also complaining a little about her eyesight then. She used to be in and out of the ER all the time, but at least she hasn’t been there for a while. She is supposed to be followed by Endocrinology, but she isn’t going to those appointments either.”

“Is there any way you know of to get her in here for a visit?” I asked.

“Well, I could just go to her house. We can give her a bus token to make it to the clinic. We could probably get her in today if she’s home,” Melissa responded. Thankfully, Melissa’s schedule is kept flexible enough that she can meet the immediate needs of patients such as Carolyn, or help out with educational needs of those being seen in the clinic that day.

I recently started working at the Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program in Salt Lake City, Utah. It is a capitated Medicaid HMO clinic that cares for just over 800 patients of all ages who have developmental disabilities. It is set up to meet both the mental health and primary care needs of this challenging population. Each patient has a case manager to direct them to desired services, coordinate their needs, and facilitate smooth transition plans from inpatient to outpatient settings. Patients also have access to psychiatrists, primary care physicians, nurse practitioners, therapists, behaviorists, a nurse, a dietician, and medical assistants, all of whom work in the clinic. Specialist providers are available throughout the University of Utah network.

When Melissa went to Carolyn’s house at 1 that afternoon, Carolyn was still in bed, too depressed and unmotivated to get up, let alone check her blood sugars or take her insulin. Melissa was able to help her get up and convince her to come to the clinic that day.

Melissa and Sandy, one of our behaviorists, joined me in the visit with Carolyn. We were able to talk about all of Carolyn’s concerns and what was keeping her from better caring for herself. Carolyn came up with two small goals for herself, related to checking blood glucose and writing it down. We were able to get her a new glucometer as her old one was not working well. We also spoke with her case manager to see if there was anything else with which we could help her. Sandy scheduled a home visit one week later, and then Carolyn would come in to see Melissa the following week. She would follow up with me in clinic in one month, and I would receive updates on her progress from Melissa and Sandy in the meantime. We also got her in touch with our mental health providers to get a better handle on her depression.

The HOME program epitomizes the pillars of the PCMH, namely coordinated, team-based, quality health care for a defined population, which is whole person-oriented. Since its inception in 2003, the clinic has dramatically decreased hospital days, lowered hemoglobin A1Cs in patients with diabetes, and improved vaccination rates in this often-resistant population. The clinic is currently making changes to increase the number of patients that we can see.

Unfortunately, Carolyn’s story is not unique, but the HOME’s ability to care for her should not be either. In most traditional care models, Carolyn would have been forgotten and left to fend for herself. In the PCMH, populations are monitored through use of an electronic medical record (EMR), so that we can discover when she and others like her are not getting the care they need. Our open access scheduling enables us to schedule same-day appointments for her or any other patient with acute issues. But these tools alone would not have been enough to help Carolyn. Melissa and our case managers have the flexibility to visit Carolyn’s home and discover many other barriers to her taking care of herself, which is an unbillable option in the fee-for-service model. The team was able to work well together, between our RN, case managers, mental health and medical providers, so that we could address many of the obstacles Carolyn faces.  

Without the team approach and services available through the HOME and PCMH models, Carolyn would not have gotten the care that she needed. And if the health care system at large does not evolve to include the principles of the PCMH, millions of others like Carolyn will be left behind.


Kyle Bradford Jones, M.D., lives in Salt Lake City with his wife Rebecca, and their 3 children Weston (7), Elijah (5), and Adelaide (18 months). Follow him on Twitter at @kbjones11


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Posted by Sonya Collins on Sep 11, 2012 8:24 AM America/New_York
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