If it’s not quite a medical home, can it still work for health care?

CLEVELAND, OHIO — Building a true medical home can require knocking on a few doors.

St. Vincent Charity Hospital has spent almost a year on a narrow, focused experiment to foster the concept that would connect patients — particularly those who use its emergency department for regular care — with full-time physicians, keep patients’ tests up-to-date and encourage them to do more to care for themselves.

The St. Vincent program is barely one year old, but early results show the promise. The success is fueled in part by better electronic records and outreach efforts can send hospital staff to patients’ homes to help them keep appointments.

Preventive health measures like flu shots have increased 30 percent. Foot exams — key to preventing complications in diabetics — have jumped by 50 percent.

Advocates say that by focusing on wellness rather than sickness, medical homes can help patients avoid costly cures and potentially cut the costs of health care.

But St. Vincent’s work also highlights the challenges of building the service. Medical residents are considered a detriment, and much of the up-front effort required to create a medical home is expensive — so much so that St. Vincent may simply keep the best parts of its experiment and give up on receiving accreditation as a medical home.

“We’re expecting challenges, and a lot of it is going to be financial,” said Dr. Adnan Tahir, St. Vincent’s chief medical officer. “If we cannot meet every single element to be called a medical home, if we can add a piece of it — like enhanced access — it’s a big step forward for our community.”

St. Vincent’s medical home clinic operates every weekday morning out of its ground-floor HealthCare Center in downtown Cleveland. The clinic started last July when internist Dr. Srinivas Merugu moved downtown to mix his 500 patients with new ones who sought treatment — and had no regular physician of their own — from St. Vincent’s emergency room. Merugu has added about 100 ER-based patients since the program started.

“I was a skeptic,” said Merugu about the potential for a new approach to change patients’ habits. “Adults do what they want to do.

“But I see it in their faces now,” he said. “They see it.”

Ninety percent of Merugu’s new emergency room patients are uninsured, and St. Vincent has financial counselors for just that program. An outreach staff goes door-to-door to make sure patients arrive at their appointments. The system also offers same-day appointments for sick patients, and same- or next-day appointments for others in the hope of improving access to medical care, Merugu said.

New software tracks the status of tests aimed at keeping patients well. As patients fall behind on tests, a color code shifts from green to yellow and eventually to red to indicate whether the tests are on time, need to be done, or patients are late getting tested, in that order.

Patients can get an almost unending amount of attention from nutrition educators and other counselors.

St. Vincent also tries to solve unrelated problems that keep people away from health care, said Lena Grafton, the hospital’s director of community outreach. Some patients avoid health care because they don’t have enough money for food, so St. Vincent workers connect them with the food bank. They also report what they find to Merugu so he better understands what his patients are facing, Grafton said.

Merugu said one of the keys to his early success is that patients only see his face. “I don’t use residents,” Merugu said. “Patients need to see the same doctor. They need to see people who know what they are doing and that know them.”

It’s a mix of technology and personal attention that’s starting to change longtime habits of some patients.

That combination solved a medical mystery for a 65-year-old woman who has had Type 2 diabetes for two decades. Her weight had fallen six pounds to 150 — a positive for cutting heart-attack and stroke risks — though it did little to help her diabetes. The A1C test that provides a kind of blood-sugar batting average sat at 9.3. The goal was 7, and over the years, the patients’ average fluctuated between 11.4 to 8.8.

“I lost a few pounds because I’m not sure of the things I need to eat,” said the woman, who asked that her name not be used to protect her privacy. She said sometimes at night she’d wake up shaky and sweaty.

After a half-hour medical checkup that moved some tests from red to green, she spent an hour with a nutrition counselor from the hospital’s Joslin Diabetes Center. The patient was evasive — embarrassed by giving the “wrong” answers about the food she ate and revealing the intricacies of her personal habits.

The patient was a senior citizen who was receiving an elementary-school styled lecture with plastic foods as props from an educator who looked to be less than half her age.

The woman’s problem came down to carbohydrates. Her low-calorie meals were high in starch. And when she ate more than the proper portions, she usually ate high-carbohydrate foods that fueled her diabetes problems.

Finally, the woman admitted she didn’t know what a carbohydrate was. She reviewed a carbohydrate-counting sheet, promised to take it home and to start a food journal, and promised to attend an additional meeting with the counselor.

“This has never been explained to me,” the woman said.

Merugu said a status report, completed in March, isn’t a true indicator of the progress made through the medical homes project. He said it will take two years of work before the true, quantifiable benefits show up. But so far, twice as many of his diabetic patients — 40 percent — are involved in self-management education and goal-setting. Foot exams are up from 30 percent of patients to close to 45 percent.

Patients still fall through the cracks. The patient tracking software isn’t easily updated if a patient is treated at another health-care system, for instance. “I don’t know if I’ll ever know they got treatment,” Merugu said.

And some could argue that the St. Vincent project had a running start on success.

The holy grail for medical homes is to improve access to people who aren’t getting regular health care – cutting the costs of the care by pushing more preventive care on patients, and keeping them away from expensive and invasive treatments in hospitals. Most of the patients in St. Vincent’s experiment already had a primary-care physician.

Just as important as how these health-care experiments are done is how to pay for them. There’s a concerted effort to make medical homes part of health-care reform. Meanwhile, insurers and grant-makers are trying to help. In Michigan, Blue Cross Blue Shield is offering higher reimbursements to doctors who adopt the medical-home concept.

St. Vincent paid for its medical homes project in part with $575,000 in grants from its parent health system’s foundation, Sisters of
Charity Foundation of Cleveland, and from health care insurer Medical Mutual of Ohio.

But paying for the project long-term may be difficult. Like most hospitals, St. Vincent has had recent financial troubles, thanks to the nation’s recession and related job losses.

The hospital laid off 50 employees in March. And the outreach efforts that sent volunteers door-to-door have stopped for the medical homes project, though the hospital hopes to do more of that in the future, Grafton said.

Ohio’s state government has probed the medical homes concept since 2003 (though mostly with the idea of providing the service to children). If the concept is to survive, governments and insurers must pay doctors to keep patients well, not just treat them when they’re sick.

“To be honest with you, if this model is not going to be supported by changes in the payment system and physician reimbursement, I really do not believe any institution is going to sustain this initiative,” said chief medical officer Tahir.