“Yes, we’ve had some patients who asked, ‘Where is the medical home?’” Moulton said with a laugh. “We even had a few employees at first who wondered where the ‘medical home’ was.”

Semantics aside, Moulton and the other team members in this multi-specialty primary care group don’t spend much time pondering the name Patient Centered Medical Home, or PCMH. What they ponder is whether this model, which integrates a team concept into improving primary care, does work, and the answer is clear: the PCMH works. The group has already reached National Committee for Quality Assurance Level 3 recognition, the highest it can achieve.

“The Patient Centered Medical Home is the future for healthcare,” said Moulton, who is Medical Director of Clinical Integration for SoFHA. “The payers have come to the table interested in pay for performance, and it’s surprised me how quickly it’s unfolded. They have really studied the outcome data, they’ve said we want these systems in place now, and we will reward you for it. They understand that we have to invest in these systems on the front end to get it done, and they’re willing to help us.”

And SoFHA is ahead of the curve on PCMH. This comprehensive Johnson City practice – which has 75 physicians, 100 total providers and 450 team members – is making the medical home work for patients. The group first began the PCMH path by starting a program for patients with diabetes. SoFHA already had a diabetic team managing care since 2006 and a highly regarded Diabetes Clinic, so the infrastructure was in place to offer those patients an even more advanced, personalized care program to help them manage the disease. An added registered nurse with specific expertise in diabetes was brought on board to serve as the Patient Care Coordinator. A faculty member at East Tennessee State University’s Bill Gatton College of Pharmacy, Dr. Rick Hess, is a Certified Diabetes Educator and has been an integral part of the Diabetes Clinic.

The Patient Care Coordinator serves as a sort of conduit for more information passing between the medical team and the patient. By mining the group’s electronic health records for data, the Coordinator can determine whether a patient has fallen out of control and needs to be seen for an adjustment in medication, can check on diet adherence, can determine whether a patient may have missed a scheduled lab test or needs new testing. Because the Coordinator has added training regarding that disease state, she or he can answer many patient questions and suggest a new course of action.

“For a primary care physician to deal with the overwhelming diabetes we have in Tennessee, you need additional resources and additional people to care for the patients and to achieve better outcomes,” Moulton said. “Some patients are initially hesitant because they’re used to having ‘their’ doctor and ‘their’ nurse, but once it’s explained to them, once they understand the PCMH, they see the Patient Care Coordinator is another person they can turn to; it shows the patient that there’s another person who really cares about them and wants to help. We’ve had a very good response to that.”

SoFHA began its PCMH program with diabetes, and has since added others: Dr. Nancy Barbarito, a board-certified family physician, coordinated a PCMH track on hyperlipidemia with Dr. Moulton;  Dr. James Hansen, a board-certified internist and pulmonologist, a PCMH for chronic obstructive pulmonary disease; and Dr. Ronald Blackmore, a board-certified family medicine physician, a PCMH for asthma. The group added two more in May: one on hypertension, headed by Drs. Kevin Sweet (board-certified internist) and Allan Colyar (board-certified family practice), and another on left ventricular systolic dysfunction, coordinated by Drs. Moulton and Barbarito.   

Moulton said SoFHA takes a very process-oriented approach to establishing a PCMH. They study the disease state; research the evidence that would support establishment of a PCMH; present the evidence to the physicians to ensure agreement on the evidence; develop the protocols of care; agree on investing in a Patient Care Coordinator; and only after all that is accomplished, start engaging patients.

As Medical Director of Clinical Integration, Moulton is charged with helping expand the PCMH within the group.

“What I try to do is build consensus,” Moulton said. “With SoFHA, we have a democracy, so all the physicians have input in the directions we take. To build consensus, what I’ve tried to help do is put a system in place that’s easy for physicians to adopt, a system that addresses the disease states of their patients and improves outcomes without adding work to an already busy day. It’s a system that will help them and improve quality of care instead of barraging them with a series of messages and labs.

“You can see the feeling that our group has for the medical home by the number of physicians who have stepped forward to develop disease states. We have a broad base of support from our physicians, the CEO, and the administrative staff to put this in place as a priority the last two years.”

Physician-owned and operated, SoFHA, has ten clinical practice sites in Johnson City supported by a state-certified reference lab and access to diagnostic imaging services. Other services include a walk-in clinic with extended hours, a sleep center, physical therapy, and a clinical research division. The group is on the Web at www.SoFHA.net.

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