SAN DIEGO – The patient-centered medical home is beginning to demonstrate a positive impact on patients with diabetes, results from a national analysis showed.
"A lot of this has not been published yet, but we see improvements in several diabetes care measures of quality, and cost savings as well," Dr. Robert A. Gabbay said at the annual scientific sessions of the American Diabetes Association. "Stay tuned, because this is coming to a primary care practice near you. It’s catching on everywhere."
Dr. Robert A. Gabbay
A new model for primary care, the patient-centered medical home (PCMH), involves a "more coordinated care system, enhances access for patients, and fosters team-based care, distributing the care amongst the team within the practice," explained Dr. Gabbay, who directs the Penn State Hershey Institute for Diabetes and Obesity. "At the foundation of all this is a payment reform system that helps to reimburse at a higher rate for all of these coordinated activities."
He described diabetes as a natural target for the PCMH because it’s a high-cost disease, it’s highly prevalent, and there are established, measurable evidence-based quality goals that clinicians generally agree upon. "The diabetes community has had early recognition of many of the key concepts of the medical home, such as population management, use of registries, supporting patients in their own self-management, and team-based care," he said.
More than 40 diabetes-focused PCMH demonstration projects are currently under way nationally, Dr. Gabbay said. He provided a progress report from projects launched by three large integrated health systems:
– Group Health Cooperative, Seattle: Improvements of 51%-59% in its bundled "composite quality score" of diabetes measures for 9,200 patients in the first 2 years, reductions in emergency department and inpatient admissions, and a return of $1.50 for every dollar invested in the PCMH after 21 months.
– Geisinger Health System, Danville, Pa.: First-year improvements in the proportion of patients with an HbA1c of less than 7.0% (from 32% to 35%); blood pressure of less than 130/80 mm Hg (from 40% to 44%); and the "diabetic bundle," a measure of nine diabetes indicators (from 2% to 7%).
– HealthPartners, Minneapolis: Improvements in the bundled measures of HbA1c, blood pressure, low-density lipoprotein (LDL) cholesterol, aspirin use, and tobacco cessation over a 4-year period (from 4% to 25%).
State initiatives have also shown improvements, said Dr. Gabbay, who is also professor of medicine at the Pennsylvania State University. For example, an assessment of 11,900 patients served by 25 of the 150 practices in a Pennsylvania-based medical home initiative launched in 2010 showed reductions in the proportion of patients with an HbA1c of greater than 9.0% (–6%), as well as improvements in the proportion of patients with systolic blood pressure of less than 130 mm Hg (12%), LDL less than 130 mg/dL (12%), those setting self-management goals (38%), foot examinations (25%), eye examinations (18%), and diabetic nephropathy screening (13%).
In a Rhode Island initiative, providers reported improvements after 2 years in the proportion of patients achieving an HbA1c of less than 7.0% (from 33% to 40%), blood pressure of less than 130/80 mm Hg (from 18% to 40%), and LDL of less than 100 mg/dL (from 27% to 42%).
In the meantime, initiatives in Colorado and North Carolina have both met National Committee for Quality Assurance benchmarks for diabetes care, as well as reductions in emergency department and inpatient admissions.
The most frequently used approaches to transform to a PCMH, Dr. Gabbay said, are implementing patient registries, upgrading electronic health records, improving care management, participating in learning collaboratives, and practice coaching.
"In Pennsylvania, it’s been very much driven by the chronic care model, which has a much stronger evidence base in terms of improving quality of care," he said. That state’s initiative also includes monthly outcome data reporting and multipayer financial incentives.
Dr. Gabbay said that he had no relevant financial disclosures to make.