New way to track medical care

Finding ways to keep patients involved and active in their own healthcare is not always easy. But a new program will soon be making it easier for patients to get involved and for doctors to provide better care at the Upper Peninsula’s largest hospital.

Marquette General Hospital will participate in a program called Patient Centered Medical Neighborhood. The program is provided through the company TransforMED. It will be used to better manage patient information.

Doctors will have a better way to see if a patient’s preventative care and chronic disease management is up to date. The program is not just for the doctors and patients at M–G–H, it will be something that will improve care throughout the U.P.

Along with its family practice care centers across the U.P., M–G–H has nominated Portage Health Systems, and facilities in Baraga, Dickinson, and Schoolcraft counties to be a part of the program.

About 157,000 Medicare and Medicaid beneficiaries in up to 15 health systems and provider organizations across the nation will begin participating in the Patient-Centered Medical Neighborhood (PCMN) demonstration project as part of a collaboration among TransforMED, Phytel and VHA Inc.

Funded by a three-year, $20.75 million cooperative agreement awarded by the Center for Medicare and Medicaid Innovation (Innovation Center), the PCMN project is scheduled to begin implementation this month.

This award is part of the Health Care Innovation Awards program, a Department of Health and Human Services initiative investing up to $1 billion to test promising new approaches that aim to improve health care and lower program costs for recipients of Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

TransforMED, VHA and Phytel will support up to six primary care practice transformation efforts within each participating community to create or continue development of Patient-Centered Medical Homes (PCMHs) into Patient Centered Medical Neighborhoods (PCMN). PCMHs connect primary care with other community-based health care providers to develop the “Patient-Centered Medical Neighborhood” concept. Designed to improve and strengthen collaborative relationships among primary care practices and other providers such as hospitals and specialists, the PCMN builds on proven methodologies and solutions to create more efficient, coordinated health care delivery networks that improve care at a lower cost.

The collaborative PCMN project plans to achieve the following goals by year three of the demonstration:

Decrease overall health care costs by $49.5 million within the 15 communities
Improve the health of the eligible patient population by a 15 percent average in selected quality measures:
Achieve a 25 percent improvement in the patient experience, Extend Patient-Centered Medical Home and Patient-Centered Medical Neighborhood learning within each of the 15 communities.

Health care organizations currently participating in the PCMN demonstration project are:

Avera St. Anthony’s Hospital, O’Neill, Neb.
Charleston Area Medical Center, Charleston, W.Va.
Columbus Regional, Columbus, Ind.
Greater Baltimore Medical Center, Baltimore, Md.
Huntsville Hospital, Huntsville, Ala.
INTEGRIS Health, Oklahoma City, Okla.
Marquette General Health, Marquette, Mich.
Northeast Georgia Health System, Gainesville, Ga.
North Mississippi Health Services, Tupelo, Miss.
North Shore Physicians Group, Salem, Mass.
Novant Health, Winston-Salem, N.C.
Orlando Health, Orlando, Fla.
Owensboro Medical Health System, Owensboro, Ky.
Via Christi Health, Wichita, Kan.
Western Connecticut Health Network, Danbury, Conn.

The collaboration will leverage TransforMED’s PCMH primary care expertise with Phytel’s population health management solution to identify and automate care gaps, patient outreach, care management, patient engagement, and performance evaluation. VHA will bring expertise in clinical quality improvement and knowledge transfer strategies. This potent combination is expected to yield significant improvements in clinical integration and clinical outcomes at lower costs.

TransforMED CEO Terry McGeeney, MD, MBA, FAAFP, who will serve as the project’s executive sponsor, said: “It’s a great time to be a primary care physician, and we are eager to get started on this exciting project. We are going to create the ideal situation for our nation’s health care system through this award, by building these medical neighborhoods on a strong foundation of transformed PCMH primary care practices that will align with the health systems and specialists to ensure that care is comprehensive, coordinated and managed throughout the communities.”

“The concept of the Patient-Centered Medical Neighborhood has enormous potential to provide a template for effective care delivery that health care providers nationwide can replicate in their communities as they progress in their journey to achieve efficient population health management,” said Peggy Naas, MD, MBA, VHA vice president for physician services.

Steve Schelhammer, CEO of Phytel, commented, “We are eager to demonstrate for health care organizations in communities across the U.S. that population health management, when done right, can ensure all of their patients receive appropriate care and are fully engaged in disease and illness prevention.”