Can The Medical Home Model Reinvent Outpatient Diabetic Foot Care?

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By Thomas Belken, DPM

   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.

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