By Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN
Editor-in-Chief of Case in Point Magazine and the Case Management Resource Guide

The following article, based on an exclusive interview with Dr. Steve Hurd, the executive director of the Marillac Clinic in Grand Junction/Mesa County, Colo., was written by Les C. Meyer, MBA. The interview took place during the Patient-Centered Primary Care Collaborative’s Stakeholder’s Working Group Meeting held in Washington, D.C., on July 16, 2009.

Moving From Complexity to Simplicity

Advances in medical technology that turbo-charge the diagnostic abilities of health care providers foster the creation of comprehensive, multidisciplinary lifetime care systems that actuate accountable  ”health assurance” options designed to transcend the health insurance model by providing necessary services to reach agreed-upon neighborhood health improvement goals. These developments also serve to unify fragmented delivery for the chronically ill, as well as enhance affordable health access to coordinated, evidence-based, interdisciplinary care delivered in the larger context of family and community.

In an effort to avoid the lifelong costs associated with the treatment of patients with complex chronic diseases, the concept of physician-led health and performance improvement continuous value enhancement (HPI/CVE) also begins to emerge. HPI/CVE is a promising approach that industry thought leaders recently urged President Obama and Congress to incorporate into national health care reform.

The HPI/CVE focus is on the economic impact of preventive care and its positive impact upon downstream expenditures rather than its immediate cost while providing the evidence of improved individual health and community economic development (and corporate) performance. The HPI/CVE process seeks to improve the quality, safety, efficiency and transparency of health care delivery by focusing on each individual’s lifelong personal health accountability, the health and per capita cost of a defined population, and patient satisfaction initiatives through which consumers define their own needs and concerns.

This HPI/CVE best-practices profile of the Marillac Clinic in Grand Junction/Mesa County, Colo., which opened in 1988, provides an overview of access issues for acute care and the enhancement of chronic disease management. It also portrays a community-based, patient-centered medical home “learning laboratory” (i.e., high-performance health system model) whose market innovations can be adapted elsewhere, and offers methods to transform legacy health insurance reform through practical and reliable HPI/CVE health assurance strategies.

Dr. Paul Grundy, director of health care transformation at IBM and president of the Patient-Centered Primary Care Collaborative, lauds the Marillac Clinic for building a smarter health system that provides team-based medicine and community health assurance. “What America needs is a patient-centered medical home model of care that redesigns the way primary care is delivered and financed,” he says.

It’s worth noting that the cost of treating people in the last two years of their lives is lower in Grand Junction/Mesa County than anywhere else in the U.S., according to the influential Dartmouth Atlas study of health care systems.

One reason is a long history of collaboration between providers and community leaders who are deeply committed to the medical home model of care’s emphasis on 24/7 access to medical consultation. The community has been committed to universal access. In addition, the local Rocky Mountain Health Plan and Mesa County Independent Physician’s Association have worked hard to develop a single-tiered system to simplify care.

Another is the region’s blended compensation system for providers, which makes payments equivalent for all major forms of coverage – commercial, Medicare and even Medicaid. This payment system is unlike most contemporary markets, in which Medicare reimbursement is lower then commercial, and Medicaid lower than both. The blended payments are made possible by aligned incentives, in which the physicians share substantially in the profits (or losses) of the health plan, which creates a strong incentive for close communication, coordination and quality oversight.

The payment system is also made possible by the not-for-profit status of all of the parties, which greatly facilitates a “shared success/shared sacrifice” orientation toward partnership. The effect of the arrangement is that all members of the community (even those with the lowest incomes or the most challenging disabilities) enjoy mainstream access to care and coordination services – while compensating providers fairly on the basis of performance – not merely the number of procedures rendered.

Dr. Raymond Fabius, CPE, FACPE, president at HealthNEXT, extols the Marillac Clinic, which builds upon the “trusted clinician” relationship to achieve meaningful productive interactions between the clinic’s patients and their doctors over time. “Research has proven the value of these clinician-patient trusted relationships through better compliance with evidence-based medical guidelines and improved medication adherence,” he says. “Since many of the clinic’s uninsured patients are also in the community workforce, employers truly benefit by improved on-the-job employee work performance.”

The Problem

Like so many communities across the U.S., Grand Junction faces a shortage of primary care physicians – a problem that’s even more acute in rural areas where there’s a low concentration of health care practitioners. Marillac Clinic is mindful of this challenge and uses a team approach to remove pressure on primary care providers (PCPs) to do most of the work or feel that they always need to be in charge.

There are other difficulties encountered at the clinic. For example, medical office assistants were expected to handle patient charts or data in the exam room differently based upon the provider’s preference, which resulted in tremendous inefficiencies and staffing frustration. Moreover, reviewing patient charts is still too labor-intensive, and practice management software is in need of improvement – lacking key “hot sync” features via electronic medical record capabilities and meaningful IT enabling technologies that work.

With medical and mental health providers having a long history of operating in separate silos, the goal of integrated care is formidable. Marillac Clinic sought to eliminate these distinctions and achieve a cultural shift that embraces holistic treatment – simultaneous care for the body and the mind. In 2000 the clinic received a grant from the Robert Wood Johnson Foundation to explore the potential of the integrated care model.

The clinic’s mission is be part of the Mesa County health improvement continuum by addressing the needs of the uninsured, spending limited funds wisely, and seeking to eliminate medical errors. Equally important is the clinic’s commitment to achieving the highest possible patient satisfaction – with the help of both patient surveys and focus groups.

Beyond that, the clinic’s leadership team’s larger concerns were that the accreditation process for medical homes places too much emphasis on registries and internal office processes at the expense of patient-centeredness, closure of care gaps, sustaining patient engagement and improving the patient experience.

The Solution

The Marillac Clinic’s guiding philosophy is to meet as many patient needs as possible in a single visit. This means that Marillac Clinic accepted the challenge of co-locating medical, dental, vision, mental health, social care and pharmaceutical services under one roof.

“The Marillac Clinic is a great example of what a redesigned payment structure and care system can do to help set America in the right direction toward quality, affordable health care and full, productive lives for all,” says Dr. Marjie Harbrecht, executive director of the Colorado Clinical Guidelines Collaborative. “This model could become a foundation on which a more simplified, accountable U.S. health care system could be built.”

As part of the clinic’s patient-centered approach, staff are expected to devote a substantial investment of their time to learning as much as they can about each individual’s life, including anything from their accomplishments, hobbies and lifestyle risk factors – both work-life and psycho-social pressures. Staffs adhere to the continuous healing relationship that starts with the receptionist who greet people by name and with a welcoming smile.

In order to eliminate waste, reduce treatment variability, and improve workflow, the clinic created horizontal process teams. This enables staff throughout the clinic to function at the “peak of their license,” helping the overall clinic practice team to operate more efficiently and effectively.

It is common for team members to assist providers and meet patient needs by entering an examination room and completing what Marillac team members call a “warm hand-off.”

This human touch often revolves around coaching patients who feel embarrassed about their condition or inability to achieve health-improvement goals involving weight loss, exercise or smoking cessation, establishing a timetable for those objectives and tracking their progress.

Since many uninsured patient populations aren’t aware of resources available in their community, the Marillac Clinic continuously provides outreach where potential patients congregate – places like grocery stores, churches and community events. The clinic’s website also includes detailed information about available services.

The Results

“The stakeholders in the health care system in Mesa County have a longstanding commitment to meet the health care needs of the entire community regardless of payer source or ability to pay. Marillac Clinic is a critical part of achieving that goal because its primary focus is the uninsured,” says Michael E. Huotari, vice president of legal and government affairs, Rocky Mountain Health Plans.

“The Marillac Clinic model of care is remarkable for its comprehensive and integrated delivery of care focused on the needs of the individual patient. Their ‘open access’ model achieves a level of integration of medical, behavioral, oral, vision and psycho-social care for each patient that is rarely accomplished anywhere else,” says Huotari.

“Rocky Mountain Health Plans has a long history of moral and financial support for the Marillac Clinic. We are currently working with them to help them preserve their philosophy and model of care as the Colorado Medicaid program expands eligibility for coverage. We expect that our collaboration will allow them to continue their innovative and effective delivery of care for the foreseeable future,” adds Huotari.

The advent of Quality Health Network brings a robust, interoperable health IT information exchange system that demonstrates “meaningful use” and provides user-friendly information exchange at the point of care.

Marillac Clinic can readily communicate to all hospitals and nearly all physician practices in the community exchanging data accurately, efficiently, and securely to provide the clinic with the reservoir of data necessary to dependably measure cost and quality. Consequently, the clinic can collaborate on evidence-based clinical guidelines and then execute meaningful “comparative effectiveness” research studies as appropriate to demonstrate what works, what doesn’t and is it worth it. The clinic also enjoys excellent referral relationships with various medical specialists and community agencies.

The clinic has transitioned from an appointed method of practice management to an open-access approach that has significantly reduced the no-show rate for this patient population to approximately 6 percent, considerably lower than the national average for safety net clinics. Open access supports low-income earners who might have trouble arranging child care or a ride to the clinic, as well as accept a temporary job assignment at the last minute that they would be hard-pressed to decline.

Interestingly enough, same-day appointment requests can be double booked if this means preventing someone from seeking costly care in the ER.

To paraphrase business icon Jack Welch: The power of simplicity is cutting through the nonsense and doing things right. That’s exactly what Marillac Clinic and its systematic, relationship-centered care model is all about.

Les C. Meyer is a seasoned health care strategist and CEO of HPI Advisors, LLC, a Denver, Colo.-based think tank. He can be reached at 303-757-6756 or Les.Meyer@HealthAndPerformance.info.