Healthcare 360: Connecting Your Care In and Out of the Doctor's Office
Deborah Reinheimer
| 4 min read
Healthcare is complicated. For many people, even those who have doctors and health insurance, it is difficult to navigate the system and access needed services.
Healthcare is also personal. Each of us has our own set of health risks, needs, circumstances and conditions.
Recognizing this, Blue Cross Blue Shield of Michigan launched its Patient-Centered Medical Home (PCMH) program in 2009 to strengthen the primary care model and facilitate the move to more team-based, coordinated care that is centered around each patient’s needs.
Roughly 1,600 primary care offices across the state have transformed their practices to provide team-based, personalized care to patients. Patients have better access to their care team, so they can get their needs addressed quickly, often preventing a costly trip to the Emergency Room or a hospital stay.
In fact, from 2009 to 2023, PCMH practices prevented $813.5 million in medical claims due to reduced hospital admissions and ER visits.
Advanced coordination, beyond traditional healthcare
Over the years, Blue Cross has supported health systems and physician organizations as they add more services to the PCMH model. Medical groups like Trinity Health IHA Medical Group, part of Trinity Health Michigan, guide many of their primary care practices into advanced patient-centered medical homes. Called advanced primary care, these practices offer comprehensive services that coordinate patient care across all settings.
At Trinity Health IHA Medical Group, Primary Care - Cherry Hill Village in Canton, the team reviews a daily list of patients and their health screenings, and they reach out to each patient who indicates a need for services. For those patients who have urgent needs, a medical social worker will reach out within 24 hours to connect them with the appropriate resource.
Sometimes, coordination of care includes connection to community health services to assist patients with things that factor into their healthcare, like transportation to a doctor’s appointment, or access to healthy food. Trinity Health IHA Medical Group even has a contract with a ride-share service provider so they can offer their patients a way to get to their health appointments.
“For patients with transportation barriers, this has really helped,” said Caitlin Valley, director of Quality and Population Health at Trinity Health IHA Medical Group. “We aim to be our patients’ hub for all the physical, behavioral and social factors that impact their health. And this results in better outcomes for them.”
For example, Valley recounts one patient who could not afford a particular device he needed to manage his blood pressure at home. Trinity Health IHA coordinators worked behind the scenes and found some grant funding to purchase the device for the patient. The patient’s care team showed him how to manage his blood pressure at home and followed his care through frequent check-ins and monitoring. The patient’s blood pressure improved and is now controlled.
Coaching, guiding and habits that stick
As the health hub for their patients, the Cherry Hill Village practice has care managers, pharmacists and behavioral health managers available for patients who need those services. This is particularly helpful for patients who have multiple chronic health conditions and benefit from having a care manager in the office who can help coordinate all their tests and appointments.
This extended care team also can provide personalized coaching and guidance, to teach patients to better manage their own condition and build habits that last.
Heidi Steinhebel, RN, BSN, CCM, Program Director for Team-based Care, remembers one patient in particular who had not been to a doctor in years. This patient had high blood sugar, high blood pressure and excess weight, all of which were leading to more serious health issues. A care manager consistently worked with the patient, helping him make sustainable, healthy lifestyle changes.
After nearly a year, the patient had lost weight, lowered his blood pressure, lowered his blood sugar, and had built healthy habits that can last a lifetime.
“We help patients develop action plans that they can stick to, based on personal interviews with each patient to understand their situation, and what motivates them,” said Steinhebel. “We meet patients where they are, and together we help them make changes that stick.”
Affordability and better outcomes
Throughout their transformation into an advanced primary care model, Trinity Health IHA Medical Group, Primary Care - Cherry Hill Village and other practices within Trinity Health’s medical group work to keep patients out of higher cost health settings.
For example, the Cherry Hill Village practice offers a weekday morning walk-in clinic, so patients can be seen before work or school. Patients with Covid-19 or flu symptoms, sore throats and coughs, or suspected urinary tract infections can get their needs addressed quickly, often preventing a costly trip to urgent care or the ER.
By managing patients’ health, offering additional hours and access to appointments, and connecting patients with community resources, they have reduced emergency room visits and hospitalizations, helping keep care more affordable.
“The advanced primary care model is our standard of care. There’s no additional cost for our patients to receive it. It’s simply our family caring for yours,” said Valley.
Learn more about what Blue Cross is doing to keep healthcare affordable by visiting bcbsm.mibluedaily.com/affordability.
Photo credit: Getty Images
