The Lehigh Valley Health Network adapted the Vermont health improvement model to meet the unique needs of its practices that were transforming into PCMHs. When asked by leadership what would be most helpful in this transformational process, the practices cited additional staff resources to manage their high-risk patients. In response, the network enhanced support to the practices by implementing multidisciplinary teams called community care teams (CCTs), which were deployed to the practices to help manage their high-risk patients. The purpose of this study is to evaluate the effectiveness of CCTs within the PCMH model by examining key utilization, quality, and process measures. The CCTs were expected to increase the overall practice effectiveness and efficiency (practice level outcomes) by offsetting some of the workload regarding the management of high-risk patients and improving the outcomes of patients directly managed by the CCT (patient level outcomes).
Methods
Setting
Serving 5 counties, the Lehigh Valley Health Network is a large health care delivery system in southeastern PA that currently operates in a fee-for-service environment but is moving towards becoming an accountable care organization. The concept of using CCTs to support practices’ PCMH development originated with network leadership. Leadership approached 7 primary care practices with the most extensive PCMH involvement to pilot the CCT initiative (1 practice declined participation). More specifically, the practices were selected based upon their prior 3-year experience with practice transformation as a result of participating in the South Central PA Chronic Care Initiative [10] and having achieved National Committee for Quality Assurance level 3 PCMH recognition. Practice selection was also based on the results of a network-wide comprehensive practice assessment which included TransforMed’s MHIQ survey [11] of PCMH capabilities and in-house surveys to capture practice characteristics and readiness for change.
Program Design
The CCTs were designed to support 3 to 4 primary care practices in the short-term management of high-risk patients with chronic disease. Much like the Vermont community health team model, each team consisted of a RN care manager who functioned as the team lead, a behavioral health specialist, and a social worker. A clinical pharmacist was added to the CCT program shortly after implementing the project and was shared between 2 teams. The team engaged in population health management for patients identified as high-risk for poor outcomes by supporting the further development of disease self-management and goal setting skills, addressing behavioral health, social, and economic problems, and connecting the patient to other Network and community resources as needed. Furthermore, given the growing evidence demonstrating the positive impact of coordinated and continuity of care post hospital discharge on patient outcomes [12,13], the CCT also played a vital role in supporting the PCMH transition care program for high-risk patients, which involved contacting patients via the telephone within 48 business hours of discharge from the hospital to reconcile medications, assess and identify issues for follow-up, answer patient questions and coordinate appropriate appointments.
As a pilot program, 2 CCTs were deployed to 6 primary care practices (3 family medicine, 2 internal medicine, and 1 pediatric) in July 2012. Prior to engaging the practice and patients, each team member participated in an extensive orientation, which presented essential evidence-based knowledge on the CCT and PCMH models and provided application training and support in information systems, network resources, and care management.