Team approach puts focus on staying well

One Sunday early this year, Elaine Markley opened her mouth to sing at the Tygart Valley Presbyterian Church in Huttonsville, West Virginia, but no words came out. “I couldn’t get my breath to sing,” she said. “By Monday night, I was in the emergency room in Elkins, and they sent me straight to Morgantown.”

Markley, an active 79-year-old, had developed a blood clot in her lung. “My son told me later he wasn’t sure I’d make it that night. I wasn’t either.” At Ruby Memorial Hospital, doctors treated her with blood thinners and other medication and got her breathing normally again. But the incident took a toll on her health. “It set off my diabetes. It really went berserk,” she said. “I used to just take a pill, and that was it. Now, I need an insulin shot every day.”

A week after she left the hospital, Markley showed up for a follow-up appointment at WVU’s Clark K. Sleeth Family Medicine Center. She had a couple of questions she hoped to get a chance to ask.

“The doctors who saw me at Ruby were there,” she said. “That was a surprise.” And so were a lot of others: a case manager, a pharmacist, and someone to talk with her about monitoring her blood sugar.

“I don’t even remember them all now,” she said. “I’ve never seen that many people at one appointment before.”

What Markley gained that day is a “medical home.” The concept is simple: identify the patients most at risk for medical complications or hospitalization, and concentrate the efforts of an entire team of health professionals on keeping them healthy.

But it flies in the face of long-standing economic incentives that rewarded doctors and hospitals for the specific services they provide – with higher payments for complex procedures and hospital visits. Recent initiatives – both by private insurers and government programs under the Affordable Care Act – are reversing the incentives to reward caregivers whose good work resulted in good health. At WVU, faculty members are leading a number of efforts to apply the concept to patients who turn to WVU physicians for care.

“In the medical home, you are a part of our practice,” said Karen Fitzpatrick, MD, who serves as medical director for the year-old family medicine project. “Your healthcare is delivered by a team that’s working together to give you the support and tools you need to improve your health. We train everyone in the office who interacts with a patient that they own that patient’s care and their outcomes.”

The medical home team provides extra support to patients after a hospital stay. Instead of waiting for the patient to call and schedule a post-discharge appointment, they’re signed up for a visit to the clinic before leaving the hospital. The patients meet with all the members of their medical home team on their first visit to the clinic and are set up for a customized follow-up plan that can include multiple appointments and phone check-ins.

For Markley, learning to control her diabetes – and adjusting her dose of the blood thinners she needs to take to avoid another clot – took some time.

Case manager Lisa Metts, RN, saw her every two weeks after she left the hospital in February, monitoring her blood thinner medication and diabetes. She set her up with home test equipment, so that she could get her meds checked without a trip to either Elkins or Morgantown.

“The weeks she didn’t come in, we talked on the phone,” Metts said. “Once everything was stable, we cut her visits back to every month, then every three months. But, I still call every month to check up on her.”

“I had a lot of questions,” Markley said. “And sometimes, when you have a doctor’s appointment, you forget to ask something, or you think you’re wasting the doctor’s time with a silly question. They never made me feel that way.

“They really listen. I was a teacher – I can tell when people are listening to me.”

Her evaluation of the medical home concept: “I think it’s wonderful. It’s comforting. You feel more secure in your care. It’s just a more efficient way of dealing with a patient.”

Her WVU doctors appreciate that feedback. But they are not relying on anecdotes to test the effort. Every patient’s record is reviewed to see if the visits and calls are having an impact on health outcomes, repeat hospitalizations, and other statistical indicators of health.

By summer, Markley’s medication was under control, and she had learned to give herself insulin shots and call in test results to the team in Morgantown. She started back at doing the things she loves: enjoying the hummingbirds and butterflies that congregate around her flower-filled yard, cooking for church events, reading, and talking on the phone with her friends and family. She hasn’t been back to the hospital.

But her favorite activity is an added one. She’s spending as much time as she can with her new granddaughter. “Her name is Abigail Elaine,” she said with a smile. “Don’t forget the ‘Elaine.’”