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.