Medical Neighborhoods Are Transforming Care Delivery in Rural Settings

Phyllis Simpson Sherard, PhD, Judit Olah, PhD, and Greg O’Barr, M.Ed, Wyoming Institute of Population Health

Fragmented health care delivery systems are associated with inefficiencies, highly variable health outcomes, not being financially sustainable, and no longer being acceptable to patients, providers, and insurers.

Delivery system and payment reforms championed by the Affordable Care Act recognize the fundamental role of local communities, health plans, and medical practices to develop multi-stakeholder initiatives to reform our nation’s health care.

However, in vast and sparsely populated states, accountable care organizations (ACOs) like those envisioned in the CMS Medicare Shared Savings Program may be unlikely to form. Wyoming, for example, has virtually no managed care presence and is home to no large, integrated health systems that span the entire state. Additionally, Wyoming’s most rural communities are located vast distances from the state’s two largest hospitals. To add to the challenge, the rural settings lack specialty services, and small hospitals lack the market power to contract for the services close to home that would be necessary to preempt referrals outside of the ACO. And yet, despite these obstacles, Wyoming is moving forward with a statewide effort to transform rural care delivery.

The Wyoming Institute of Population Health, the recipient of a $14 million health care innovation award from the Centers for Medicare and Medicaid Innovation, has brought together hospitals, providers, and communities all across Wyoming to address three drivers of rising health care costs: 1) failures of care delivery, 2) failures of chronic care management and transitions across sites of care, and 3) overtreatment, often associated with failures of care coordination or care communication. Fourteen hospitals and 21 medical practices, representing more than 50% of Wyoming’s primary care providers, are voluntarily participating in this innovative initiative.

Five key strategies are being implemented in Wyoming’s medical neighborhoods:

  1. Patient-centered primary care medical homes (PCMHs), focused on wellness and comprehensive primary care services, form the core of Wyoming’s medical neighborhoods and serve as consistent, central coordinators of care for medically complex patients.
  2. Care Transition RNs provide education and facilitate continuity of medical care as patients with complex conditions transition between hospitals and post-acute sites of care. Working with PCMHs and other providers, these RNs work with patients to establish individualized care plans, improve the patients’ confidence to self manage, increase patient and family engagement, and decrease health care costs by reducing avoidable hospital readmissions and associated penalties.
  3. Telehealth Physician Desktop Solutions have been deployed across Wyoming, expanding the state’s telemedicine system to increase access to specialists, improve coordination between sites of care for high-risk patients, and facilitate effective medical decision making.
  4. Pharmacists are being integrated with PCMH interdisciplinary care teams to support medication therapy management. These community pharmacists play a vital role as the medicationutilization connection between patients and their health care providers.
  5. Access to donated, in-date, prescription medications for uninsured and underinsured patients has been expanded statewide to help providers develop and support comprehensive care plans for low-income patients.

Projected to save Wyoming an estimated $33 million in health care costs over three years, the initiative’s five component strategies have been designed to ensure that patients achieve the greatest possible care experience and benefit from well-coordinated, effectively communicated care and seamless transitions between sites of care.

Quality Management and Payer Partnerships
In Wyoming’s medical neighborhoods, PCMHs provide a comprehensive framework for quality management. Participating PCMHs have become learning organizations, and clinical quality reporting and performance evaluation have become core functions of their practice management. Data on quality, performance,
and costs are available and used for learning and continuous quality improvement. Timely analysis and practice-wide evaluation feedback allow for quick corrective actions where needed; transparency increases patient engagement, improves provider satisfaction, and increases staff engagement.

PCMHs have made dramatic progress in the area of quality metrics reporting in Wyoming’s medical neighborhoods. Practices are now reporting to the Institute nine clinical outcome measures (five preventive and four high-risk monitoring indicators). Cost-containment goals (e.g., avoidable ED visits, hospital admissions, and readmissions) have been successfully linked with quality goals.

With little experience in measuring and reporting cost and quality, the practices were initially challenged by the resource burdens associated with regular reporting. Over time, however, payer incentives and the Institute’s support to help the PCMHs identify and meaningfully manage their complex patient populations have enabled the reporting transformation at the practice level. All of Wyoming’s payers are increasingly responding to the quickly evolving PCMH quality and performance evaluation transformation and offering care management incentives to further propel the momentum of quality reporting capabilities in primary care. Though PCMHs were initially designed within the rollout of CMS’s Pioneer ACOs, Wyoming has found its own path to linking of performance-based reimbursement relationships between care providers and its major payers.

Critical Success Factor: Collaboration
Health care transformation requires a paradigm shift from the outdated model of patient care delivered in silos—a model posing danger to patient care, satisfaction, and safety—to a care delivery model that is well communicated and well coordinated across the care continuum. Population health delivered in a medical neighborhood requires a patient-centered care delivery model, comprehensive assessment of the patient’s needs in a primary care setting, and development of individualized care plans to manage and improve the health of that patient that draw upon a broad range of services across the health care continuum and the community.

It sounds very simple, but the medical neighborhood concept, to be successful, must create collaborative relationships among health care providers that previously viewed themselves as disconnected, competing organizations. PCMHs are coordinating the care of their patient panels and are reporting improved clinical outcomes associated with chronic disease management and preventive screenings. Specialty providers are utilizing telehealth to bridge geographic distances, and clinical site-to-site consultation is on the rise across Wyoming. Hospitals are sharing accountability for the care of complex, high-risk patients and are now collaborating on the development of care transition plans. Wyoming, with its historic tendency to form collaborative relationships that work, has developed a unique solution to the challenge of health care reform.

About the Wyoming Institute of Population Health: The Wyoming Institute of Population Health, a division of Cheyenne Regional Medical Center, is committed to building bridges between communities and health systems. The Institute was created to develop strategic platforms that proactively address the evolving needs of patients, providers, and communities across Wyoming. (307) 663-2914