Larry Lawhorne’s Patient-Centered Medical Home pilot project takes a team approach to managing care for patients with dementia
For the caregiver of someone suffering from dementia, help can seem far away in the middle of the night.
So it was recently for a woman whose husband, instead of sleeping, suddenly decided he had to go somewhere. Larry Lawhorne, M.D., described the episode involving an unnamed patient and his wife.
“He was really confused. He was bound and determined to go someplace and do something,” Lawhorne said. “Finally, in her exasperation, she just said, ‘OK, do it.’
“And she flings open the door, and it’s windy and rainy. He looks outside and says, ‘You know, the weather’s kind of bad. I don’t think I’ll go.’”
The crisis passed, but Lawhorne said the woman shared her despair over it during her next visit with him. “Her statement was, ‘I showed a man with dementia the door. I must be a terrible person.’ As we discussed it I said, ‘Well, you know you could have called,’ because she had my cell phone number. She said, ‘It didn’t seem like a medical problem,’” Lawhorne recounted.
“And all of a sudden I realized, well, I suppose technically it wasn’t. But it was certainly a problem that a Patient- Centered Medical Home for People with Dementia should be able to address.”
The Patient-Centered Medical Home (PCMH) is a relatively new concept that has been drawing attention around the United States in recent years, both as a way of improving patient care and as a means of delivering care more efficiently. The federal government has encouraged the trend by funding a variety of PCMH pilot projects.
One is a project led by Lawhorne, professor and chair of the Department of Geriatrics in the Wright State University Boonshoft School of Medicine.
A new model
Lawhorne’s project is a geriatric study of the Patient-Centered Medical Home (PCMH) for People Living with Dementia. The pilot program will provide 30 households with easy access to both electronic health records and an interdisciplinary team for medical care. “What we’re hoping is that this model will help people stay at home longer, safer, and also help the caregiver with caregiver stress,” he said.
Lawhorne said a goal of the project is to determine the costs of providing care with the PCMH model. A common theme of the projects, he said, is “better care for the individual, better health for the population, and at a lower cost. Not at cheap cost, but at lower cost in the sense that we’re trying to create more efficiency within the system and avoid duplication of x-rays, blood work, and other interventions.”
He hopes the PCMH model also will decrease trips to the emergency room and reduce the number of falls and hospitalizations.
“Ultimately,” said Lawhorne, “we’d like to see the person maintain their person - hood as long as they can.” He uses the phrase “person-centered” instead of “patient-centered” in describing his medical home project.
Several factors played in the creation of the pilot project.
In 2010, State Rep. (now Sen.) Peggy Lehner sponsored a bill to fund the PCMH Education Pilot Project; it made $1 million available for 44 projects around the state. Wright State received $45,000 of that amount.
During the same period, the federal Affordable Care Act created the Centers for Medicare and Medicaid Services’ (CMS) Innovation Advisors Program, an initiative to test new models of health care delivery and payment. Lawhorne was one of 73 individuals from 27 states and the District of Columbia, and one of only three in Ohio, selected to participate in the program.
Finally, the Wyatt Family Foundation made a gift to fund the pilot project.
As part of its mission, the Innovation Center seeks to offer technical support to providers to improve the coordination of care and share lessons learned and best practices widely throughout the health care system.
It is committed to transforming federally supported programs to deliver better care for beneficiaries, better health for populations and slower growth in expenditures through improvement for Medicare beneficiaries.
What is a PCMH?
A patient-centered medical home is not an assisted-living facility, but rather a concept for care delivery. “It’s a place, and maybe a virtual place, where the person can go where all their medical needs are coordinated and concentrated,” Lawhorne said. As a patient, he said, “I have a family there of health care professionals and paraprofessionals who are going to make my house a home.”
In a typical PCMH, the patient or caregiver works not just with a doctor, but with a team. Every team member is familiar with the patient, Lawhorne said, and the patient can access the team in a variety of ways, each one appropriate to the circumstance. It might be through a “patient portal,” or internet connection, or by email or phone, he said.
“It all comes down to timely access and response to what the person’s need is,” Lawhorne said. “And, it doesn’t necessarily have to be a doctor or advanced practice nurse. It could be whoever has the skill set and the competence to deal with it.”
Under the PCMH model, the patient might have fewer office visits where the main purpose of the visit is for patient information or education. Lawhorne suggested that information about diet and exercise for patients with Type II diabetes, for example, could be given to the patient electronically. “It’s tailored for that person, but they don’t have to come into the doctor’s office to have that piece of paper handed to them,” he said.
Group sessions also might replace some individual visits. Lawhorne sees an advantage in that approach in that group members can function somewhat like a support group.
The PCMH allows the physician to make the best use of his or her time. “You’re not going to have nearly as many office visits as we have now, from the physician’s perspective, but the office visits that you have would be longer, and would be much more focused on things that haven’t been covered otherwise, and the physician would be reimbursed a little better for those calls,” Lawhorne said.
Tailored to needs
Lawhorne’s PCMH concept will be tailored to the needs of people living with dementia. An important element will be what Lawhorne calls “stage- specific screening.”
“For instance, if someone is approaching end-stage dementia, we’re really not interested in screening for colon cancer,” he said. “We’re not nearly as concerned about their cholesterol, for instance, because that becomes a moot point for them, and interventions that either screen for it, follow it up, or treat for it, become more of a burden than anything else to that person,” he said.
The focus will be on people with moderate to severe dementia,” Lawhorne said. “We’re trying to keep them home longer and safer, with the caregiver in mind. There comes a point in every caregiver’s life where they just can’t do it anymore. It’s not their fault—in fact, it’s far from it. But, the longer the person can stay home, and as long as it’s to the advantage of both the person and the caregiver, then we want to be able to keep them there.”
A big challenge to the PCMH concept is reducing the number of emergency room visits and expensive tests without sacrificing care. Lawhorne envisioned a common scenario—a person with dementia who has fallen, leaving the caregiver to wonder how badly the person is injured. In many cases, a home examination and a follow-up visit by a team member may eliminate the need for an ambulance run and a CT scan.
Another important element of the PCMH for people living with dementia will be the development of advanced health care directives. For example, Lawhorne said, it’s beneficial to discuss ahead of time what should be done when the person with dementia no longer can swallow.
“Feeding tubes for people with advanced dementia are probably futile interven - tions,” he said. “They probably make very little difference in terms of outcome, and they’re very invasive. The person doesn’t understand why they’re there, and the feeding tube is often pulled out and has to be replaced. So, let’s talk about that now. Let’s talk about the pneumonia that the person is probably going to get because they don’t swallow very well. What are we going to do when that comes? Let’s have that conversation now.”
Quantifying the cost of health care delivery through the PCMH is a crucial objective, Lawhorne said. “How much is it going to cost us to do this, to deliver good care in this model, and what’s the difference between what it costs us in this model and what it’s costing in the current way we do it?
“The idea is that you would decrease the number of complications from whatever the chronic diseases are, you would decrease emergency department visits because you’re taking care of these things in a more timely way, and you’re arming the patient with much more information,” he said.
Understanding true costs and savings is key to making the PCMH economical. Lawhorne suggested a more aggregate view of costs in developing a billing plan.
“If you look at fair market value for the social worker, a dietitian if we need one, whoever else we need, if you look at the fair market value for them, the number of hours they put in, and the number of hours that we put in as physicians and nurse practitioners, we look at all the income we get from Medicare, and we say OK, it cost us $2,500 for all the services we delivered in a year, and we were reimbursed a total from Medicare of $1,300, so the shortfall from what we spent and what we received in payment was $1,200,” Lawhorne said.
“So what that means is, if Medicare were to give us $100 per month, as a per member per month fee, then we’d break even, which is all we want to do.” The monthly fee would be justified if it can be shown that the PCMH model will result in fewer hospital admissions and tests. Lawhorne said the pilot project will compare its data with existing data for Montgomery County.
Setting up the project
Lawhorne is setting up the project now. He has identified 30 households to participate in it. He expects the project to run between June 2012 and June 2013. “We’re going to try to figure out, per household, how many hours of face-to- face visits take place, whether they are in the office or the home, how much time is spent on the phone, and the distribution of resources from physician to nurse practitioner to social worker to medical assistant,” he said. “We have ideas about this, but we really need to know what it actually takes (to operate a PCMH for people living with dementia), and then compare that to our models.”
Lawhorne envisions a PCMH for people living with dementia would manage about 200 households. Between 20 and 30 households would change each year as patients died or transitioned to institutional care.
“The bottom line is, we want to figure out how much it is going to cost to deliver this, and can we make a case to Medicare and to other insurance companies,” Lawhorne said. “We’ve done some modeling of this. Basically, what we think we could save is somewhere around $60 to $80 per household per month. This could save Medicare tens of thousands of dollars per patient. So the return on investment is not bad.”
And for the caregiver, the middle of the night might not seem quite so lonely.