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Just seven minutes with your physician // an utter disconnect between your physician and specialists // a place to go only when you need care now // but a system in which you truly are at the center?

Medical Homes: Collaborative Care

By Linda Keslar // Photographs by Joe Fornabaio // Winter 2010
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medical homes

joe fornabaio for proto

Medicine has changed for patients at Aesculapius Medical Center in South Burlington, Vt. No longer a place for patients to visit only when they’re sick, it’s literally their medical home, where they receive everything from onsite nutritional consultations to prescriptions for swimming and support group meetings at the local YMCA.

Primary care physician Jennifer Gilwee is a firm believer that disease prevention is the key to a long, happy life. But during almost a decade in the South Burlington, Vt., practice she shares with eight other physicians and three nurse practitioners, prevention has been tough to implement. In a practice that handles 18,000 people, closely monitoring patients required more staff and expense than the physicians could afford. “I never felt I had a good handle on all aspects of my patients’ care,” Gilwee says.

During the past year, though, Gilwee’s practice, Aesculapius Medical Center, has changed the way it operates. As part of a pilot program the state of Vermont and several private health insurance companies are funding, the practice has become what’s known as a patient-centered medical home. Paper patient files are being converted to electronic health records, and the nine physicians can now refer patients to a community health team paid for through the program. The team includes a nurse, a clinical social worker, a nutritionist and an administrator. Physicians, who meet with the community team at least monthly to review cases, are getting to know patients better and are staying in touch after they leave the office.

Although such changes may seem relatively minor, they represent a sharp departure from the way most medicine is practiced, and the impact can be life-changing. Consider a new patient in Gilwee’s practice, an obese man in his mid-thirties who was diagnosed with diabetes. Pre–medical home, he might have gotten a session with a nurse educator to talk about monitoring insulin levels and giving himself daily shots, and perhaps to go over recommendations for diet and exercise. But it would have been his job to make follow-up appointments to measure his blood sugar, and no one would have had time to check whether he was going to the gym and losing weight.

With the new system, he gets frequent calls and e-mails from staff members alerted by a computerized patient-tracking system. The team’s nutritionist has designed a reduced-carbohydrate diet and an exercise plan for the man, who meets with the team nurse monthly. He has lost 45 pounds and is managing his diabetes without insulin. “If we can work with someone who’s early in the process of developing a chronic disease and teach him how to stay healthy, that’s going to save money for the patient, the practice and society at large,” says Gilwee.

Vermont’s pilot is one of more than 90 current or pending medical home demonstrations. Last fall the Obama administration announced plans to involve Medicare, which covers some 45 million people, in several pilots as well, and health reform legislation before Congress would fund expanded testing. Although programs vary, all focus on enabling primary care teams to spend more time with patients and on providing services, such as nutritional and mental health counseling, not normally available in physicians’ offices. The goal is to improve the quality of care and achieve better outcomes—and, by fostering patient health and reducing hospitalizations, to save money.

The need to achieve those objectives couldn’t be more urgent. The U.S. health system is falling short by many measures—quality of care, patient access and safety, among them—and critics blame that on how care is delivered and financed. After decades of experiments to organize care, most patients are still left largely on their own. They decide when to be seen, and by whom, in a fee-for-service model that rewards volume—more lab tests, more specialist examinations—and undervalues primary care.

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Primary Care Stats: Primary Numbers

What does primary care really cost—in terms of time and money?

Inside a Medical Home

A small Vermont practice epitomizes the push for collaborative care. Make a virtual visit with our audio slideshow.


1. “Proof in Practice” [Patient-Centered Primary Care Collaborative, 2009]. The publication offers the most extensive and up-to-date compilation of medical home pilots and demonstration projects, as well as reports analyzing the model’s promise.

2. “Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental Before and After Evaluation,” by Robert J. Reid, Paul A. Fishman, et al., The American Journal of Managed Care, September 2009. This in-depth one-year evaluation of Group Health’s medical home pilot provides the first empirical evidence of the benefits of adopting this new type of care.

3. “A House Is Not a Home: Keeping Patients at the Center of Practice Redesign,” by Robert A. Berenson, Terry Hammons, et al., Health Affairs, September/October 2008. The authors, pointing out that the greatest payoff of the medical home will probably involve patients with chronic conditions, stress that practice redesign should apply to all patients, thereby lessening the chances that it actually increases health care spending.

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