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A New Way to Deliver Primary Care

Imagine if you had a trained nurse whose job is to be your personal health guide, a care coordinator.

Not only could you call them, whenever you feel like it, but they call you.

PHONE CALL: Good morning. This is Kyle, the care coordinator from Metro, how you doing? How have things been going since you left the hospital?

They call you to see if you have questions after a doctor’s visit. They want to know about any issues you’re having. They talk with all your doctors and specialists, to make sure everyone is on the same page and that treatments are coordinated.

And imagine that this care coordinator is your advocate within the system.

This is the promise of a new model of healthcare, called a “medical home.”

It’s designed to give you that personal guide, and put all your healthcare under one umbrella.

WEISS: And I think the reason that it’s called “home” is the notion that everyone should have one.

Anne Weiss is a senior program officer at the Robert Wood Johnson Foundation, a national philanthropy that’s funded medical home initiatives across the country.

WEISS: I think one of the most frustrating things I have experienced as a patient, and most all of us have experienced, is the complete absence of coordination. To me the concept of the home is the notion that there is one place that knows where you are, knows everything about you, and is helping you make decisions and staying in touch with you.

Minister Kenneth Taylor serves at Mt. Pleasant Baptist Church on Cleveland's east side.

It hasn't been easy for him to stay healthy.

TAYLOR: I been through a lot, with its ups and downs, with this diabetes. I never thought I was going to get on track with it.

In 2009, MetroHealth enrolled Taylor, and more than 10,000 other Northeast Ohio patients in a medical home pilot program.

And the results are promising.

Patients in the program had more office visits in the first year, but they had 35% fewer hospitalizations and about 7% fewer ER visits than similar patients not enrolled.

And Metro’s overall costs were lower for patients in the medical home.

Dr. Jim Misak is a physician at MetroHealth.

He says the program works because it adds a new member to the healthcare team:

MISAK: The care coordinators really are the secret sauce to this program.

Care coordinators not only help patients navigate the system, they keep people from falling through the gaps. They check up on them. They make sure they understand their doctor's instructions and take their meds. They connect them to services they might need, like mental health or substance abuse.

Minister Taylor was a little taken aback when he first got a phone call from his care coordinator.

TAYLOR: At first I took it as a little-she was pushy! How dare she call me and tell me, you know?

You can hear Geneva Jones laughing in the background.

She's Taylor's care coordinator.

They've worked out a good relationship now.

JONES: I think he realized the value of the relationship when he was able to call me and say this is happening, should I go to the ER or do you think I should get an appointment or I don't have this medication, what's available?

The program has paid off for Taylor. He feels better. His diabetes is under control.

He trusts his medical team, which is made up of Jones, his care coordinator, his primary care doc, Kenneth Frisof, and other specialists.

Taylor talks about how, when he was in a bad spot, Dr. Frisof went to personal lengths to make sure he stayed on track.

TAYLOR: I remember coming here and I couldn't get my insulin one day and he reached in his pocket, and said this is not a loan, but go get your insulin.

These programs are still in the experimental phase and have a huge hurdle to overcome: how to pay for it all.

Right now, insurance doesn’t cover these services.

But as the healthcare industry tinkers with how best to deliver care, the medical home could end up with a starring role.

anne.glausser@ideastream.org | 216-916-6129