Implementation of the first patient-centered medical home for inflammatory bowel disease has resulted in decreases in emergency room visits and hospitalizations and improvement in quality of life in the first year, according to a study of IBD patients at the University of Pittsburgh Medical Center.
Results of the study, Decreased Emergency Room Utilization and Hospitalizations, and Improved Quality of Life (QOL) in the First Year of an Inflammatory Bowel Disease (IBD) Patient Centered Medical Home (PCMH), conducted by Miguel D. Regueiro, MD, FACG, University of Pittsburgh Medical Center, were presented at the American College of Gastroenterology 2016 Annual Scientific Meeting in Las Vegas, NV in October.
The PCMH is a team-based health care delivery model led by a health care provider that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. This model has existed for primary care but not for patients with chronic diseases who see a specialist. Though there are several IBD treatment centers in the U.S., the IBD PCMH differs from an IBD treatment center in several ways – most notably, in the IBD PCMH, the gastroenterologist acts as the principal care provider for the patient. *see below
“The work represents the first patient-centered medical home for inflammatory bowel disease. The patient-centered medical home is a joint payer-provider initiative to improve the quality of the patient experience while reducing cost,” according to Regueiro.
In the IBD Medical Home, a gastroenterologist leads an interdisciplinary team of health care specialists, providing “whole person” care to those with Crohn’s disease and ulcerative colitis. In the first year the IBD Medical Home enrolled 308 patients, aged 16 to 50 years, with Crohn’s disease or ulcerative colitis. All had IBD as their primary reason to seek medical attention and all had the same (UPMC) health plan insurance.
Regueiro continues, “Many of these patients had a poor quality of life and high utilization of emergency room care and hospitalization. These patients frequently went to the ER or hospital for IBD symptoms including pain. Through this multidisciplinary total care specialty medical home for IBD, we were able to show a significant improvement in the quality of life, and reduction in the unplanned care [including] ER utilization and hospitalization. The decrease in unplanned care was nearly fifty percent for ER and hospitalizations compared to the year prior to enrollment in the IBD Medical Home. We believe that these findings are important and will help us and others develop new models of care for IBD and potentially specialty medical homes for other chronic diseases.”
ibdreporter had an opportunity to ask Dr. Regueiro some questions about the study and the how the IBD PCMH may impact patient care in the future.
TG: Can you give a real-life example of “whole person” care and how it benefits patients?
Miguel Regueiro, MD: A 32 year old man who has had four prior intestinal resections for Crohn’s disease and perianal abscesses. He presented to our medical home after visiting the emergency room 12 times in the preceding two months. When we schedule visits, the IBD Medical Home schedulers ask each patient the top three things they would like to get out of the visit. His answers were: 1) help with my pain, 2) assistance with my housing, and 3) advice on diet. Interesting that not one of [the patient’s concerns] directly mentions “Crohn’s disease.” When he met us for the first medical home visit, we had him meet with our dietitian, social worker, psychiatrist, nurse practitioner, pain specialist, colorectal surgeon, and myself (gastroenterologist). We quickly realized that although he has Crohn’s disease and it had been severe that this was not the cause of all of his symptoms – it had more to do with stress over his living situation (just fired from a job and worried he will be homeless), how to pay for his medications, and how to cope with his Crohn’s disease. Through this team based approach, I am happy to say that he has not gone to the ER in 6 months, has his pain controlled without opioid narcotics, feels in better control with his symptoms of Crohn’s, and has found another job. What he said to my nurse on his last visit: “your IBD Home saved my life. I am grateful for all of the attention and caring people that take care of me.” The team based approach is at the core of this model and most important component to whole person care.
TG: The PCMH provides principle and total care for IBD patients and utilizes open access scheduling, remote monitoring, and telemedicine – can you explain these features – open access scheduling, remote monitoring and telemedicine?
Miguel Regueiro, MD: Open access means that patients can contact, via the web portal or phone call and get a live person and immediate response to get in for an appointment that day or the next day without waiting. Remote monitoring is utilizing smart phones and apps to track symptoms and monitor patient progress. Telemedicine is akin to Skype in which we can do virtual visits ‘face to face’ remotely without having to bring the patient physically into the office. Our psychiatrist probably uses telemedicine the most to visit with patients and assist in coping mechanisms for their stress and disease.
TG: Can you elaborate on QOL improvements and which were most significant for the patients in the study?
Miguel Regueiro, MD: In the study presented at ACG, we wanted to improve Quality of Life utilizing the short form inflammatory bowel disease questionnaire (SIBDQ). We found that we were able to significantly improve quality of life within 3 visits and sustain this for the duration of the first year.
TG: Is this a realistic model of care outside of IBD centers, i.e., can this be implemented in private practice?
Miguel Regueiro, MD: Excellent question. Honest answer, I don’t know. However, I do think that any practice that can utilize team based care with principle and primary care for a cohort of patients with a specific chronic disease can do this. I also think it is important to work with an insurance company around this population based model. It is probably easiest to transition in an academic center that has an IBD Center (of excellence) to a medical home, but I believe we are headed toward these new care models and that some private practice groups are beginning to do this.
TG: In what ways does the IBD PCMH change the payor/provider relationship, compared with traditional health care models?
Miguel Regueiro, MD: Unlike traditional health care models, the IBD PCMH has partnered directly with the Payor (UPMC Health Plan) to manage a population of patients. The provider (me) meets with the Health Plan (Payor) regularly to review utilization and quality data. I am fortunate to have a Payor who strives to improve the quality of a patient’s experience first and foremost. Unlike traditional health care models where the payor and provider did not know each other, did not work with each other, and sometimes would have an adversarial approach to each other, we work together as a team to help our patients. It’s a unique and refreshing approach to patient care and the data and information that the health plan has provided the providers has been important in improving patient care.
TG: In addition to reducing ER visits and hospitalizations for IBD patients, would this model also help to reduce redundancies in services, such as lab reports, tests, etc.?
Miguel Regueiro, MD: Definitely, yes. One key aspect is for us to reduce variation of care between providers as well as decrease utilization of diagnostic testing. This is done by following care pathways but also having our medical home team practice ‘smart medicine.’ Meaning, it’s common for us to ask each other, ‘do you really need that test, will it change management?’ Also, by getting all patient records in advance we can quickly determine the recent testing and avoid duplication of unnecessary tests.
TG: Do you see this model being utilized for IBD patients, on a larger scale, in the future?
Miguel Regueiro, MD: Yes, I think this will expand to more patients in our own center, but will be a model for many patients with IBD across the country.
TG: In what other chronic diseases might this model be implemented to benefit patients/decrease cost?
Miguel Regueiro, MD: I think any chronic disease with patients whose principle care if from a specialist would qualify for a specialty medical home model. Examples that we are currently evaluating at UPMC are oncology, heart failure, multiple sclerosis, and sickle cell to name a few.
*Moving from IBD Centers to IBD Homes – What’s the difference?
- The IBD Center collaborates with the hospital/medical center and is built around the healthcare team. The gastroenterologist is a consultant and is referred patients by providers
- The IBD Patient Centered Medical Home collaborates with the insurance company and puts the patient at the center of the care model with gastroenterologists as principal care providers. The gastroenterologist is referred patients by the payer in a population based approach. Support comes from insurance company