BestPractice
April 8, 2016

One Wednesday morning as she walked through the door of East Baltimore Medical Center, internist Laura Sander got a call: A patient with uncontrolled diabetes had been admitted to another health system’s Emergency Department (ED). Within a half-hour, Sander was on the way. That week, the woman would receive a home visit and then, the following week, she would come into the office for an extended appointment. Between visits, someone from Sander’s team called the patient to check on her.

Concierge care? In a way, yes. The young woman is one of 70 enrolled in the Priority Access Primary Care (PAPC) pilot, which Sander directs from East Baltimore Medical Center. The pilot is a collaborative effort between Johns Hopkins Community Physicians and the Priority Partners Managed Care Organization, which is jointly owned by Johns Hopkins HealthCare and the Maryland Community Health System.

The program aims to keep Medicaid patients out of the ED and the hospital by providing very intensive primary care services that are integrated with behavioral health care and social services. A highly successful strategy to decrease unnecessary ED visits has been direct access to providers: Patients call, text or video chat with PAPC providers 24/7 for acute needs. Also, PAPC gets a notice within 15 minutes when one of the patients is admitted to a hospital or ED in the state, not just within the Johns Hopkins system, thanks to CRISP, Maryland’s health information exchange.

The pilot’s inspiration is the Hot Spotters program that physician Jeffrey Brenner launched in Camden, New Jersey; Atul Gawande wrote about it in The New Yorker. The program’s patients are the costliest among Priority Partners’ population, with “incredibly complex medical and psychosocial needs,” says Sander, and a history of ED and hospital admissions. Priority Partners looks at its claims data to identify candidates for the program, although Sander encourages Johns Hopkins providers to make referrals too. Sander makes the final determination of eligibility.

Working side by side with Sander is a multidisciplinary team composed of nurse practitioner Kate Shockley; certified medical assistant Sherrell Byrd-Arthur, who serves as a “health navigator” to help patients negotiate the health system; licensed clinical professional counselor Laura Fukushima; and community health worker Brian Adams, who connects patients to community resources and coaches them in disease self-management.

Since the PAPC pilot began a year and a half ago, ED visits among its patients have dropped 30 percent and admissions 41 percent, and it has shown a 2-to-1 return on investment. It is set to run through 2016.

A key piece of the program’s success, Sander says, is that it provides behavioral health care. When patients come in for a primary care visit, they spend 45 minutes with Sander or Shockley, then another 45 minutes with Fukushima.

“We have more patients with depression than with hypertension. Thus we’re really focusing on mental health care alongside traditional primary care. For us, they’re inextricable,” says Sander.

Each primary care visit incorporates motivational interviewing and education on disease management. Sander and her colleagues help patients pick a goal, such as losing 60 pounds. “Since that large a goal can seem overwhelming, we help them choose intermediary goals and identify the barriers that stand in the way of achieving them,” she says.

PAPC providers carve time out of every day for home visits. New program participants receive a home visit as part of their introduction to the program. Patients with chronic conditions will receive periodic visits to help with medication reconciliation. Those with acute needs will be treated in the home, if appropriate, or sent to the ED. All patients discharged from the hospital receive a home visit as well. “As a provider, it’s a privilege to step into someone’s home and have them share their space with you,” Sander says.

Patients see their providers frequently at the start of the program. “We work to meet patients where they are, to get to know them and then slowly build their confidence and trust to work on their larger health challenges,” says Sander.

At the same time, the program works to address patients’ considerable social needs. The community health worker helps patients apply for housing vouchers and fill out Social Security documentation, for example. His job is to identify barriers to good health care and connect patients to the social system.

“We’re happy to say that by doing exactly what we set out to do, which is reconnect high-cost patients to primary care, we’ve improved their health and saved money,” Sander says.

High-Intensity Primary Care Internist and preventive care specialist Laura Sander, medical director of the Priority Access Primary Care pilot, explains the program's aims: To keep Medicaid patients out of the Emergency Department (ED) and the hospital by providing very intensive primary care services that are integrated with behavioral health care and social services. Its patients' ED visits and admissions have plummeted, and the program is showing a 2-to-1 return on investment.