Last year, high blood pressure, obesity, and uncontrolled diabetes were slowly killing 46-year-old Phil Smith.

He wasn’t using his insulin properly and couldn’t seem to stick to an exercise regimen or a healthy diet. There’s nothing unusual about this story so far. In fact, now that a quarter of the U.S. population suffers from chronic illnesses like heart disease, diabetes, or asthma, most providers see some version of it play out every day.

Unfortunately, caregivers too often come in only at the end of the story -- when patients show up at the doors of the clinic or emergency room with advanced disease or life-threatening complications that are both damaging to their health and extremely expensive to wrestle back under control.

In Smith’s case, though, there’s a plot twist.

Drew O’Donnell, MD, Smith’s physician at Family Medical Associates of Durham, invited him to take part in a pilot program for patients with uncontrolled diabetes. Rather than being left to manage his condition alone in between check-ups, Smith was assigned a personal care manager -- Margarette Wrenn, RN.

John Anderson, MD

Wrenn showed Smith how to keep a blood sugar diary, and now reminds him to bring it in before his scheduled doctor’s appointments. She calls Smith two weeks after each appointment to make sure he’s following his doctor’s advice.

If he’s having trouble doing so, Smith gets help from Wrenn in accessing nutrition, exercise, and behavioral counseling services and providers.

Within four months of joining the program Smith lost 25 pounds, but his blood sugar remained uncontrolled. Wrenn dug a little deeper, and discovered Smith wasn’t able to keep good tabs on his blood sugar because he couldn’t afford glucometer test strips.

“A lot of our patients don’t realize the seriousness of diabetes complications or what resources are available to them,” says Wrenn, who was able to help Smith get the supplies he needed. “They tell me things they don’t mention to their doctor. It gives them another chance to ask questions.”

This pilot program represents a whole new approach to diabetes management in the primary care setting -- and a growing effort by Duke Primary Care to take a more active role in managing patients’ health.

It’s a big change from the time when doctors simply waited for patients to come to the office, treating problems as they arose, says Scott Joy, MD, medical director of Duke Primary Care Pickett Road. “Now we work as a team to provide care that’s integrated and proactive. We’re setting up safety nets to catch our patients so they don’t fall through the cracks.”

By making preventive care more accessible and more effective, these tactics aim to help patients avoid more costly health problems down the line. They’re also drawing a road map for navigating the uncharted territory of health care reform.

“We’re entering a time that presents many opportunities and challenges,” says William J. Fulkerson Jr., MD, executive vice president of Duke University Health System (DUHS). “We’re trying to anticipate what we need to look like in five years and what we need to change in order to be successful as we move forward. Our primary care providers, perhaps more than any others, are best prepared to help us define the best care delivery models for the years ahead.”

Predicting the Future

Redesigning health care has been talked about for some time, but it’s taken on a new, pragmatic sense of urgency following passage of the Affordable Care Act last year.

Since most of the health care reform provisions in that act have yet to be implemented, no one can say with certainty what care models will eventually emerge to meet health care reform’s goals of greater access and efficiency. Nevertheless, everyone agrees that redesigning care is a necessity.

Not only are health care costs spiraling, sweeping changes in reimbursement are about to collide with an increased demand for services as 32 million currently uninsured patients are set to gain coverage under health care reform.

“A lot of indicators point to a future in which reimbursement mechanisms will shift the financial risk of caring for patients away from employers and insurers and toward providers,” says Fulkerson. Broad cuts in Medicare and Medicaid reimbursement are forecast too. “We anticipate providers will eventually be financially rewarded for delivering high-quality, low-cost care, and penalized when they don’t.”

The stage is set for a fundamental shift away from the current fee-for-service model, which pays doctors for episodes of care, diagnostic tests ordered, and procedures performed regardless of outcomes. But how and when that transformation will occur remains unclear.

A more value-driven financial model, which emphasizes quality and encourages hospitals, doctors, and other providers to work together to deliver patient care more efficiently, is the subject of much discussion in medical journals as well as in leading newspapers.

Realizing that model is the ultimate goal behind DUHS’s “top to bottom commitment and effort to redesign care,” says Michael Cuffe, MD, DUHS vice president for medical affairs. “Our mandate is to increase access to high-quality care while controlling costs,” he says.

“To do that, we need to prevent unnecessary emergency room visits, hospitalizations, and readmissions. We need to improve transitions of care between primary care, specialists, and the hospital. We need to equip ourselves to better manage different populations of patients with chronic disease. Ultimately, we need to create a more patient-centered experience.”

Home, Sweet Medical Home

That’s a tall order given that health care has traditionally been fragmented among independent primary and specialty care offices and hospitals -- with the traditional fee-for-service payment structure providing little financial incentive to coordinate care services among them.

One of the most promising models to emerge is what’s been dubbed the “patient-centered medical home.” Sometimes described as primary care on steroids, medical homes create well-oiled teams of physicians, advanced-practice providers, nurses, social workers, and other caregivers who work together to manage all of a patient’s needed care services, both within the practice and beyond its walls.

Endorsed in recent years by organizations from the American Medical Association to the National Committee for Quality Assurance (NCQA), the medical home model has its roots in pediatrics, where practices often coordinate care for children from birth though adulthood.

“We’ve always organized our patients’ medical care as well as their psychosocial care,” says Elaine Matheson, a pediatric nurse practitioner at Durham Pediatrics. “Medical homes also involve creating real partnerships between providers and patients, which has been a defining feature of pediatrics -- we involve the whole family in the decision-making process.”

An early pioneer in the medical homes movement, Duke began in the 1990s to move the concept into the adult-care arena.

“We recognized the need for a fundamental shift in the way we provided care that focused on comprehensive treatment for our patients, not just their acute situation,” says Lloyd Michener, MD, chair of the Department of Community and Family Medicine.

Realizing that the medical-homes model would need to be backed by supportive reimbursement policies, the department worked with the State of North Carolina in 1997 to pilot one of the first networks that pays care teams to coordinate health services for Medicaid patients -- $2 to $3 per enrollee per month.

Today, there are 14 networks statewide, known as Community Care of North Carolina (CCNC); estimates indicate the program has saved the state more than $1.2 billion to date. For demonstrating that coordinated care can improve the health of communities while reducing overall health care costs, CCNC is looked to as a national model for care redesign -- as are other medical-homes-based models initiated at Duke.

In 2009, the Marshall I. Pickens Clinic, part of Duke’s Division of Family Medicine, became one of the first practices in the Southeast to be officially recognized as a patient-centered medical home by the NCQA. Today, Duke Primary Care is adopting the medical home model throughout its 24-practice network, and official NCQA certification is expected soon.

Ultimately, says Duke Primary Care’s chief medical officer John Anderson, MD, “We want to create continuous, long-term, healing relationships between patients and providers, rather than episodic ones.”

Primary Care 2.0

Transforming a primary care practice into a medical home takes some rejiggering of systems and processes, of course.

Patients need ready access to their care team, and the care team has to communicate and coordinate vast amounts of information not only to their patients, but among the team and with external care providers.

Jane Satter, MD

In the Duke Primary Care (DPC) network, for example, moving toward a more patient-centered model of care has entailed major changes to make it easier for patients to get appointments when they need them.

DPC practices were the first in Duke’s health system to switch to so-called “open access scheduling” to offer patients same-day appointments, the first to extend hours to provide more urgent care and after-hours access, and the first to allow patients to book appointments online, using Duke’s Web-based patient portal (HealthView.dukehealth.org).

These changes have increased practice efficiency as well as patient and staff satisfaction, says Anderson. “By leaving substantial blocks of the primary care provider’s schedule open, we’re able to respond to patient needs when they arise -- and typically we can assign those patients to their usual provider, which improves continuity of care and enables us to take care of things like preventive screenings the patient may be due for at the same time.”

Information technology is also critical to the job of coordinating patients’ care across a complex array of providers and locations, says Anderson. Next year, Duke Primary Care will be the first group to assist in a multi-year rollout of an approximately $50-million transformation of the Duke ambulatory electronic medical records system.

The health system has also initiated an evaluation of an inpatient electronic medical record system that will standardize inpatient systems and also provide a seamless flow of information between inpatient and outpatient records. Already, DPC providers are employing IT tools to improve their ability to manage care for some patient populations.

For example, DPC has launched an electronic diabetes registry to better track care for those patients. The registry supports efforts such as the diabetes management program at Family Medical Associates by enabling the entire care team to input and view each patient’s interventions and test results.

Early data gleaned from the registry are also proving the success of the pilot program -- according to O’Donnell, more than half of enrolled patients saw improvements in their hemoglobin A1C levels, a measure of blood sugar. “That’s almost certainly due in part to our improved ability to track their progress and adjust care as needed,” he says.

Care teams are also using electronic registries to streamline patient visits. Nurses can update a patient’s medication list, perform a rapid-result A1C test, and enter the new information into the patient record before the doctor even enters the exam room.

“We have so much more information at our fingertips now,” says Jane Satter, MD, practice medical director at Hillsborough Family Practice. “In a prior era, we would have said, ‘Let’s wait and see what the lab work shows.’ Now, the lab work can often be done before I see my patient. I can pull up the results right then and adjust her medication on the spot.”

Satter says these and similar exam-related efficiencies can enhance the quality of the time she spends with her patients. “It gives us time to talk about how they can modify their lifestyle in a way we couldn’t do before.”

Reimbursing Value

Ironically enough, the decline of the fee-for-service payment structure may be what finally lends traction to widespread adoption of these collaborative, prevention-oriented models of care.

Already, Fulkerson says, insurers are showing interest in negotiating fixed prices for physicians and hospitals for bundled patient care. “If we can deliver high-quality care for less cost, we’ll share the reimbursement savings. If we can’t, we will have to share the risk of the extended costs,” he says.

Those pressures are driving a national trend toward integrated health systems, which allow pooling of resources and also control costs by improving negotiating strength with vendors and insurers. As a result, more community physicians, specialists, and hospitals are looking to affiliate with larger health systems.

While Duke’s health system has been in existence for more than a decade, it continues to grow -- particularly in primary care. Already one of the state’s largest primary care networks, Duke Primary Care has doubled in size the last five years alone. Currently, it comprises 140 providers at 24 practices in seven counties, who see a combined 470,000 patients annually.

Plans are in place to build more practices and acquire practices with highly accomplished doctors who will deliver care that is consistent with Duke standards.

The health system also plans to hire additional providers, including nurse practitioners and physician assistants, whose skill sets will enable Duke to expand opportunities for patients seeking access to high-quality care -- whether it’s provided in minute clinics, urgent care and other ambulatory sites, or primary care offices.

“It’s our responsibility as a health care system to pioneer ways to provide the right level of care at the right venue, at the right time, by the right providers,” says Cuffe.

From Duke’s perspective, having a strong primary care network is the cornerstone of its ability to provide an optimal continuum of high-quality care across the health system. “Only a fraction of patients require specialty care,” says Ted Pappas, MD, vice chair for administration in the Department of Surgery.

“But when they do, it’s essential for our system to make that care safe and seamless from start to finish.”

Integrated systems are the backbone of a new model of reimbursement called the Accountable Care Organization (ACO) -- a sort of macro version of the medical home. The concept of an ACO is to bring together providers, clinics, and hospitals into an integrated health system that works as a unit to share resources, trim costs, and boost quality care.

Although the theory has yet to be put into practice, ACOs are gaining widespread interest for what they may be able to achieve. The model “emphasizes value rather than volume,” says Anderson. “It emphasizes strengthened clinic integration across a delivery system. It requires primary care, specialty care, and hospital-based delivery models to communicate and integrate so that you limit testing and transitions of care to those that are necessary and essential.” Ideally it would cover some internal infrastructure and IT costs, he notes.

Systems would be held accountable for the quality and affordability of patients’ care, and would receive financial bonuses and share some of the savings if performance goals were met. As the employer, provider, and insurer for nearly 59,000 employees and dependents, Duke is in the unique position to take a lead in partnering with its delivery system by integrating many components of an ACO-like model into the plan design for Duke employees.

“The concepts of integrated physician networks, disease management, and aligned incentives for employees and providers are all part of our overall strategy to manage our costs,” says Kyle Cavanaugh, Duke’s vice president for human resources.

The future may be uncertain, but it’s innovations like these that will ultimately help it unfold. “Duke continues to be at the forefront of care redesign,” says Cuffe. “That will prepare us for whatever road health care reform takes.”