Intermountain builds a primary care model for 'at-risk' patients

When faced with the fact that only 5 percent of the patient population was responsible for nearly half of the total amount spent on healthcare each year, Utah’s Intermountain Healthcare had a decision to make.

It was obvious that these patients, the most vulnerable in the U.S. healthcare system, were falling through the cracks. Primary care doctors up against a universal influx in patient volume could not set aside enough time and attention to treat the multiple chronic conditions — physical, social and psychological — presented by this most at-risk group. Hospitals were unable to offer these patients personalized, cost-efficient care.

“We need to acknowledge that most of us don’t spend our lives sitting in a doctor’s office. Most of us spend our lives at home in our communities,” said Wendy Wolf, MD, CEO of the Maine Health Access Foundation. “And when people leave the hospital, when they leave the doctor’s office, they have to go home and figure out ‘how the heck do I do what they just told me I need to do.’”

All the while, readmissions have been racking up alongside costs across the industry and patients went home as frustrated as ever. At the behest of affected patients and providers alike, Intermountain decided to build what it calls a Personalized Care Clinic (PCC), an initiative already starting to show positive outcomes, according to Tim Johnson, MD, medical director of the Intermountain Medical Group, and David Henricksen, regional assistant operations officer of Intermountain Health.

[See also: ACOs can help medical homes succeed.]

The PCC has the look of a patient-centered medical home, Johnson explained, but the services it offers for a specific patient demographic facing complex, ongoing medical issues is what sets it apart.

The team, which is ever-expanding, includes the following professional types: two internal medicine physicians, a part-time palliative care physician, a physician’s assistant, an RN care manager, a psychiatry APRN, two Licensed Clinical Social Workers, a pharmacist, a Certified Diabetes Educator, four medical assistants, a Patient Services Representative, and a clinical manager.

The clinic “functions like a primary care office with more resources to coordinate care, treat mental health conditions, address financial challenges and manage complex medical issues,” Johnson said during a presentation at the 2014 Maine Health Management Coalition Symposium in Portland, Maine.

But whereas most PCPs can’t focus on acute care utilization, the Personalized Care Clinic can, all while coordinating and collaborating with a given patient’s unique team of specialists.

The PCC model does not replace primary care for vulnerable patient populations, Johnson and Henrickson said. Rather, it facilitates a “temporary transition of primary care, coordinating a patient’s treatment plan with primary care teams,” Johnson explained.

Intermountain’s Personalized Care Clinic lists its top 5 diagnoses as: other malaise/fatigue, depressive disorder, diabetes, anxiety (not otherwise specified) and backache NOS.

Even though the Intermountain’s Personalized Care Clinic is still quite young, it does tend to a philosophy at the top of the healthcare collective mind.

“Our mission is helping people live the healthiest life possible,” Johnson concluded.