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A Comprehensive Primary Care Initiative to Improve Health of High-Risk Patients


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Patients with chronic medical conditions often don’t receive adequate education or support to help them manage their conditions. As a result, many of them fail to recognize symptoms that should prompt them to call their primary care physician. Instead, they tend to wait until their condition gets much worse and end up going directly to the Emergency Department, which frequently leads to hospitalization.

Now, thanks to an initiative launched by the Centers for Medicare and Medicaid Services and other healthcare insurers to help primary care practices deliver enhanced and better coordinated medical care to high-risk patients, some patients are becoming adept at disease self-management and enjoying a better quality of life. In addition,
they require fewer visits to the Emergency Department and are less likely to be hospitalized. 

The Comprehensive Primary Care (CPC) initiative, which was launched in October 2012, is a four-year program designed to achieve the Institute for Healthcare Improvement’s “triple aim” of better health and better care at lower costs. Phelps Medical Associates practices are among 481 primary care practice sites in seven states participating in this initiative. The practices, which were selected through a competitive application process, receive financial support on behalf of their Medicare beneficiaries.

The goals of the program are for primary care physicians to:

1. Manage care of patients with serious or multiple medical conditions

2. Ensure that patients have 24/7  access to care by phone or  patient portal

3. Deliver preventive care,  including medication management  and review

4. Engage patients and their caregivers

5. Coordinate a patient’s care with  his/her other healthcare providers

“This is the direction healthcare is heading in,” says Judith Sapione, RN, Clinical Quality Manager, who oversees the CPC initiative for Phelps Medical Associates. “The goal is for people to learn self-management skills and be engaged so they can participate in their care. For example, if patients with congestive heart failure begin to gain weight, which is usually caused by fluid retention, they know to call their primary care physician instead of waiting for the condition to get worse and going straight to the Emergency Department.”

When Phelps Medical Associates patients are identified as having high-risk needs, their physicians can refer them to one or more of the program staff, which includes: 

a patient care navigator, a social worker who can make referrals for diabetes education, medication  management, wound care, or drug or alcohol counseling, and can help with assisted living or nursing home placement, set up a home health aide, or help a patient  access community services or transportation;

a clinical pharmacist, who works  with patients to  help them manage their medications;

an RN case manager, who  provides education about disease management information and  follows up with patients after they  are discharged from the hospital; 

an RN care coordinator, who  follows up with patients who are  discharged from the Emergency Department and provides assistance with less complex cases. 

“Having the comprehensive care provided by this system keeps the patient at an appropriate level of care, therefore avoiding frequent ER visits and multiple hospital readmissions,” says Ms. Sapione.

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