Piedmont Clinic serves many stakeholders – its member physicians, their staff, hospitals and especially its patients.
A big piece of value in healthcare comes from the quality of care the Clinic provides its patients. Piedmont Clinic has several ongoing initiatives aimed at improving quality and efficiency, including care management and the patient-centered medical home.
Care Management Works
The Opportunity: Reducing the cost of healthcare is a national focus, and many cost-reduction efforts are focused on caring for people who have two or more chronic conditions, such as diabetes, congestive heart failure or hypertension. In fact, the Robert Wood Johnson Foundation estimates that one-third of total healthcare spending is associated with the care provided for the more than one in four Americans with multiple chronic conditions. Piedmont Clinic identified an opportunity to provide practical, cost-efficient care to fill the gaps that typically occur when patients receive care in various locations.
How Piedmont Clinic Took Charge: A key way to help lower healthcare costs is by educating and engaging patients who live with chronic conditions using a variety of tools and resources. As part of its population health management efforts, Piedmont Clinic care advisors, who are either registered nurses or registered medical assistants, enhance patient care and serve as a member of the care team.
By reviewing reports from health plans and internal Clinic resources, care advisors identify patients who need extra support. Some of the common warning signs include inconsistent prescription refills, a sustained spike in medical costs and frequent emergency room visits. Once a patient is identified, care advisors then look more closely at the patient’s records to validate a need to intervene. The next and most crucial step is that care advisors listen.
They contact patients to gain an understanding of their personal situation and challenges because a wide variety of factors – including knowledge, financial concerns and stress – can lead to non-compliance and declining health. With this knowledge, care advisors work with each member of the care team to implement a personalized plan. This team approach is vital to ensuring a successful outcome for the patient, and is the basis of the Clinic’s population health management program.
The Results: The Piedmont Clinic care management program is a great success. Mammograms, pneumonia vaccinations, tobacco screenings and colorectal screenings have all increased during the past few years. This has been a priority for the Clinic. Preventive measures, such as health screenings, support early detection, education and treatment, which can make a world of difference in the cost of care, and more importantly, in a patient’s quality of life.
Patient-Centered Medical Homes Off to a Promising Start
The Opportunity: The current national healthcare system is inefficient and the payment system does not pay adequately for preventive care and counseling. This financial constraint limits the type of proactive care that effectively prevents or manages chronic conditions. The traditional healthcare structure can be a burden for patients who have intensive needs and must schedule and keep appointments with multiple healthcare professionals in different locations.
How Piedmont Clinic Took Charge: Piedmont Clinic has simplified the patient experience through more coordinated care. A key way the Clinic has done that is with a patient-centered medical home (PCMH) model of care. In a PCMH, healthcare providers deliver comprehensive primary care that emphasizes prevention, wellness and chronic disease management. A physician leads the medical team to direct all aspects of a patient’s care and builds a strong partnership among all parties involved. Recent studies have shown the promise of PCMH – one found a 15 percent decrease in emergency room visits and 18 percent fewer inpatient admissions.
Piedmont Clinic is sponsoring some initial practices in the PCMH University Program through the Georgia Academy of Family Physicians. The yearlong program will guide its practices to help achieve official recognition and certification. After certification, Piedmont Clinic will work to help broaden the PCMH program across more Piedmont Clinic practices.
The Results: Since the program began in May 2014, patients involved in the PCMH have expressed high satisfaction with this new approach. The Clinic has heard that patients feel empowered to take a more active role in their health and think the PCMH will help make it easier for them to understand and take advantage of the services available to them.
 Anderson G. Chronic Care: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation, 2010.
 Harbrecht, et al. “Colorado’s Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such As Reduced Hospital Admissions.” Health Affairs, 2012.