Successful models Coordination of Care

Successful Model for Rural and Underserved Communities

Lakewood Health System

Geographic Area: Cass, Morrison, Todd, Wadena counties and portions of Crow Wing Couny

Description:A medical home takes an integrated, whole person approach to health management. It applies 21st-century technology to old-fashioned, personalized medical care. A medical team collaborates to form and execute an individualized care plan to help patients cope, and even thrive, with multiple ailments.

The health team includes the patient, and, depending on the patient, it might include a pharmacist, a psychologist, a medical specialist, a physical therapist, an occupational therapist, a home health nurse, the patient’s spouse, even a hospice coordinator or nursing home worker. It always includes the care coordinator. The care coordinator is a key figure in educating patients, verifying records, assuring complete, up-to-date care, communicating immediate needs to the medical home provider, and accessing appropriate care for the patient.

At Lakewood, physicians decide which patients are eligible for the health care home. This requires patients who agree to be active participants, in addition to having the potential to benefit from the medical home.  Benefits can be expected when patient have three or more chronic ailments, four or more prescriptions, poor understanding, or severe/complex conditions. Most medical home patients are over the age of 65, but pediatric patients are also included as determined by their health care needs.

Every medical home patient gets a doctor visit of at least 30 minutes, double the usual time. All 11 primary care doctors reserve several slots a day for the care coordinator to fill with the most complex/urgent medical home patients who need immediate care.

To cement patient ownership of their care, each patient has a three-ring binder with medical records, contact information and educational materials that are updated at each clinic visit.  They get monthly newsletters for educational purposes which also remind them of the medical home access availability.

Through the early and successful implementation of the medical home, Lakewood Health System has become an advocate and role model, in Minnesota and nationally. With 11 family-practice doctors using the approach to offer better, more comprehensive, evidence-based and more efficient care for an ever-expanding population of complex patients now numbering 524, Lakewood Health System has become a pioneer in 21st Century quality care.

  • Physicians are happier with their role in the process because they are able to administer better care.
  • Patients are assured of swift communication and access to their chosen medical home provider and specialized care coordinator.
  • Counselors, educators, home care nurses, pharmacists and therapists are able to communicate their recommendations in a timely, effective fashion, usually via the care coordinator, contributing to the team care philosophy.
  • Administration sees an efficient pattern of care delivery using doctors, physician assistants, nurse practitioners, nurses and ancillary personnel working at the highest level of their training.
  • Minor definition and responsibility changes can be made easily.

A transformation in care has taken place at Lakewood Health System, through the adoption of a medical home model.

Background: The American Academy of Family Physicians, the American College of Physicians, the American Osteopathic Society and the American Academy of Pediatrics developed the principles behind the medical home. In 2007, a Lakewood Health System (LHS) quality improvement team educated the administration, board of directors and fellow staff about the patient-centered medical home. Throughout that year and the next, LHS developed organizational principles.

LHS began designating personnel and developing its medical home in early 2008. A care coordinator was hired. A new form of communications using the Internet was developed. Follow-up, supervision, medication refills, preventive care and evidence-based medicine were made part of Lakewood’s new computerized system.

To open up more primary care provider time, LHS turned to the use of physician assistants and nurse practitioners and an urgent care department. The physician extenders became responsible for more of the immediate, uncomplicated care of the population. The overall care of the non-medical home patients continued to be accomplished as it had been done previously but with some increased efficiency due to the influences of the Urgent Care and the medical home principles.

FUTURE: July 1, 2010, state funding for medical home reimbursement will be available in Minnesota. A Patient Advisory Council will start this year, funded partly by a $2,000 state grant. Further integration of the medical home team particularly through care plans and automatic referrals to diabetic educators, pharmacy and occupational therapy is in the process of development.

Contact: Lakewood Health System developed a Medical Home Training Package. The cost is negotiable depending upon quantities with the possibility of distribution through state and regional nonprofit organizations. A booklet describing the development of this medical home is also available at minimal cost. Contact Kristen Svobodny at (218) 894-8577. 

Dr. John Halfen, medical home director
Lakewood Health System
49725 County 83
Staples, MN 56479
(218) 894-8590

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Updated Monday, March 10, 2014 at 12:28PM