Can The Medical Home Model Reinvent Outpatient Diabetic Foot Care?

There are certain protocols/algorithms that physicians follow within the hospital setting. When a patient with diabetes comes into the emergency department with an infected ulcer, a cascade of events takes place: lab tests, X-rays, wound cultures, blood cultures and consults to the appropriate specialists. Medicine, infectious disease, vascular, endocrinology and podiatry personnel usually comprise the “team” that assembles to take care of this patient while he or she is in-house. The chart, whether it is paper or electronic, serves as a means to disseminate and share information among the specialties.

   This level of communication is often lacking in the outpatient setting. The vital interactions that take place in the hospital are absent or diluted in an outpatient setting. We can attribute some of this to logistics but it can also be due to a lack of effort to overcome the obstacles that prevent higher levels of communication. This is where patient-centered medical homes and accountable care organizations come into play. A patient-centered medical home encourages a level of teamwork and access to information that would benefit many patients’ situations. Our standard for an outpatient surgery patient is to obtain a medical clearance from the primary care doctor prior to surgery. We order lab tests, EKGs and other tests per the protocols of the patient’s medical doctor.

How Patient-Centered Medical Homes Can Facilitate More Comprehensive Treatment

Recently, I performed an elective surgery on a patient with diabetes and the patient had difficulty in healing his incision site.

   Even though the patient had gotten clearance from his primary care provider (PCP), I dug a little deeper. Turns out that the patient’s last HbA1c was around 12 and the results were at least a year old. Had patient-centered medical home protocols been in place, I would have had access to the HbgA1c and would have postponed this elective procedure. Patient-centered medical homes allow for sharing of information in real time, which will help to minimize complications and situations like I have described above.

   A patient-centered medical home can help to provide an outpatient team concept, led by the PCP, to make healthcare more effective and efficient. Having a more detailed model in place that clearly defines the roles of each team member (specialist) will help avoid redundancies. Millions of healthcare dollars are wasted ordering labs and imaging that physicians already performed, or on studies that would not have been deemed necessary per quality-based assessments.

   By implementing a system that allows seamless access to information and test results, we can minimize expensive redundancies. Recently, I had a patient in the office with a hallux fracture. Another facility took the radiographs and there was no disc. The report was very nondescript. To treat the patient effectively, I needed more information. As a result, I had to take a second set of X-rays for accurate management.

   On a busy clinic day, a couple of minutes spent searching for something as trivial as a lab test or X-ray adds up when it happens repeatedly and before you realize it, you are falling behind. As reimbursement continues to decrease, being as efficient as possible is our best defense. Whether it is utilizing your electronic medical records to their fullest or adopting a model like patient-centered medical homes, we need to take advantage of the resources that are available to help keep our practices viable.

   In limb salvage, a delay in treatment can be the difference between success and failure. When red tape and logistics slow the obtaining of critical information, there is a negative impact on patient care.

   I encountered a patient with a recurrent abscess, a chronic ulcer and a history of osteomyelitis. The patient previously saw another physician in a different facility. She received incision and drainage with debridement, and the physician had started the patient on empiric antibiotics. While the physician was waiting for the cultures, the infection continued to fester. Eventually another debridement was required in addition to proper antibiosis after the cultures came back. After the fact, we received the cultures from the previous hospital. This information would have provided us with a better idea of what bacteria we were dealing with and could have possibly prevented the second surgery. The flow of information that medical homes promote would have simplified patient care instead of complicating it.

How Patient-Centered Medical Homes Are Shifting The Acute Care Model

Patient-centered medical homes and other accountable care organizations are the most current models of care being promoted by the Centers for Medicare and Medicaid Services (CMS) and the insurance companies to enhance patient care, improve efficiency, and make healthcare more affordable. They aim to strengthen the clinician-patient relationship by replacing episodic care with coordinated care and long-term healing relationships. The ultimate goal of the medical home models is to give patients superior care while controlling costs and opening communication between each layer and facet of patient care. Consider the current alternative:

   “Sixty-eight percent of specialists reported receiving no information from a PCP prior to a referral visit,” note Gandhi and colleagues. “Twenty-five percent of PCPs reported that they have not received any information from a specialist four weeks after a referral visit.”1

   One of the goals of patient-centered medical homes is to stop rewarding the “acute care model” and start placing an emphasis on a continuous chronic care model that promotes care coordination. This care comes from a team that the PCP leads. The PCP is the coach. He or she directs the coordinated care for the patient by providing for the patient’s healthcare needs and arranging for appropriate care with other qualified clinicians.

A Closer Look At Diabetic Quality Measures

As specialists within the medical home model, we need to understand where we fit into this equation. There are specific diabetic quality measures that one must report in addition to specific requirements that patient-centered medical homes require. These specific diabetic quality measures are:
• Diabetic foot exam and diabetic shoe size, monofilament testing
• Smoking cessation

   Some of the specific patient-centered medical home requirements are:
• Having a reporting system in place that documents key registry data (test results, labs, etc.) to the PCP
• Having a reporting system that alerts you if a patient did not go for an ordered test, and you inform the PCP
• If a patient makes an appointment but doesn’t show up, you alert the PCP
• Sharing information about the treatment plan and goals
• Ability to send and receive electronic medical records securely

   By following the patient-centered medical home standards, we are falling in line with the specific testing, protocols and treatments that have been deemed essential for providing enhanced patient care. The culture in healthcare is changing. The business model that managed care companies and hospital systems operate under is shifting gears. Prevention is the new buzzword.

   In a recent article in USA Today, the CEO of Kaiser Permanente discusses the current state of healthcare and how his system has already adopted practices and principles that patient-centered medical homes and other accountable care organizations are structured around.6 By adopting protocols on prevention, Kaiser Permanente has reduced the rate of serious complications (stroke, sepsis, etc.) and improved patient care and satisfaction. In doing so, the company is on average 15 percent more cost-effective than all of its competitors.

Key Insights On Complication Prevention

Every patient with diabetes should have a comprehensive foot exam at least once per year (this is one of the requirements for a PCP’s meaningful use). It is our responsibility to provide the primary care docs with a diabetes risk grading score. Patients deemed as higher risk (score) — patients who have peripheral arterial disease, neuropathy, foot deformities, history of ulcers, pre-ulcerative lesions or amputations — should get screenings at more frequent intervals. Researchers have documented that when podiatry is involved in patient care, there is a significant decrease in limb loss and a substantial cost savings.4,5

   As the cost of healthcare continues to skyrocket, physicians regardless of specialty have to take measures to keep these costs down. Insurance companies are constantly auditing charts and billing, looking for the slightest reason to reject a claim. Developing healthcare that is more efficient and cost-effective will ease the scrutiny placed on healthcare costs. The sooner we can assimilate ourselves into the system, the sooner we can reap the rewards and utilize these models to better manage and care for our patients with diabetes. Most importantly, we need to continue to demonstrate the important and often limb saving and life enhancing nature of our services.

   Dr. Belken is in private practice at Foot Healthcare Associates in Michigan.

References
1. Gandhi TK, Burstin HR, Cook EF, et al. Drug complications in outpatients. J Gen Int Med. 2000;15(3):149-54.
2. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathetic Association. Joint Principles of the Patient-Centered Medical Home, March 2007.
3. BCBSM Physician Group Incentive Program Patient-Centered Medical Home and Patient-Centered Medical Home-Neighbor Domains of Function Interpretive Guidelines, V4.2 2012-2013. Available at www.bcbsm.com .
4. Carls GS, Gibson TB, Driver VR, et al. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc. 2011; 101(2):93-115.
5. Sloan FA, Feinglos MN, Grossman DS. Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. elderly. Health Serv Res. 2010; 45(6 Pt 1):1740-1762.
6. O’Donnell J. Kaiser Permanente CEO on Saving Lives and Money. USA Today. Published October 23, 2012. Accessed December 3, 2012.

   For further reading, see “When Diabetic Foot Ulcers Can Be Managed At Home” in the October 2004 issue of Podiatry Today. To access the archives, visit www.podiatrytoday.com.