Bon Secours' Advanced Patient-Centered Medical Home Redistributes Care Coordination Workload

Bon Secours' Advanced Patient-Centered Medical Home
Redistributes Care Coordination Workload

Bon Secours Medical Group used to bear the brunt of medical care: preventive and chronic care, medication compliance, triaging new complaints. But that model created a bottleneck and was not sustainable, says Jennifer Seiden, administrative director, population health, and Lu Bowman, population health market program manager, for Bon Secours.

With the advanced patient-centered medical home, the care team divides up the labor, creating a more fluid care team redesign, and an ultimately more efficient healthcare model.

Now what we're working on is the 'C' in this equation, the care coordination piece of it, the care team and the duties that are new to the ambulatory healthcare system. Together it equates to the advanced patient-centered medical home (APCMH), they explained.

The old way of thinking is that the provider was almost like a target, or the bull's eye. Everything went to the provider to do: the preventive, the chronic, refilling meds, triaging new complaints, getting tests results called back to patients, adding referrals. It's a bottleneck. It's not sustainable and it certainly doesn't lead to satisfied providers or an effective, efficient care delivery system in the ambulatory setting.

Now Bon Secours Medical Group uses the care team for the division of labor. Every team member has a responsibility that is delineated in the principles of the patient-centered medical home. Team members are used to the highest level of their training and licensure ability. It requires an intensive training and ongoing support program with biweekly meetings and a great deal of education; it truly is almost a medical model of education when you learn about the chronic disease processes.

There's also a social work component. Bon Secours is compiling social resources that are needed for the care team. It's a big community of nurse navigators, of the care team, and so forth. The biweekly meetings have upwards of 50 to 60 people come together to do continuing medical and nursing education. All of that helps equip them with the knowledge to flow those interventions out from the provider and help that provider do their job.

This is just more of a fluid care team redesign where it delineates a little bit of each of the roles and responsibilities of that care team and what they do. Certainly their provider still has a pivotal role in this but we are able to ease that load, they concluded.

Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial OutcomesPositioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes describes how Bon Secours's 600-provider medical group has primed its providers to employ a broad mix of team-based care, technology and retooled care delivery systems to maximize quality and clinical outcomes and reduce spend associated with its managed patients.

In this 25-page resource, Ms. Seiden and Ms. Bowman share how a reframed approach to care transition management and chronic care management pays off in improved population health and decreased spend.

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P.S. -- You may also be interested in these value-based reimbursement resources: