- Establishing a patient-centered medical home model in safety net clinics may lead to more primary care visits and less emergency department use among Medicaid beneficiaries, according to a new study published in the American Journal of Managed Care.
Researchers compared seven patient-centered medical home (PCMH) safety net clinics in the greater Los Angeles area with 110 traditional safety net clinics to examine whether the PCMH model could effectively reduce unnecessary and avoidable ED use.
"Safety net clinics play a pivotal role in delivering both primary and specialty care to millions of low-income Californians," wrote the authors from the University of Southern California, LA Care Health Plan, and Inland Empire Health Plan.
In 2011, California authorized a Medicaid waiver mandating the enrollment of seniors and people with disabilities (SPD) in managed Medicaid plans, leading to an increase in the number of patients with chronic conditions in safety net clinics.
Emergency department use is almost two times higher among Medicaid beneficiaries than those with primary insurance, constraining emergency resources and unnecessarily raising the cost of care.
With the shift to the PCMH model in greater LA safety clinics occurring during the mandated switch of SPDs to a managed Medicaid plan, researchers used this as an opportunity to examine what was a previously unstudied consumer population.
Researchers hypothesized that a PCMH model -- which emphasizes team-based care coordination, preventative care, and improving access to primary care – may be able to cut costs and avoid the use of unnecessary services tied to a high-use population.
However, with the increase in the number of chronically high users spurred by the mandated switch of SPDs to Managed Medicaid plan, researchers also explored whether the effectiveness of the PCMH model would be impacted.
According to the study, Medicaid claims data from the beginning of 2011 to the end of 2013 showed that safety net clinics shifting to the PCMH model saw a significant decline in ED visits.
After implementing the PCMH model, safety net clinics saw a ED visits decline by 70 visits per 1000 members per year (PTMPY) and avoidable ED visits drop by 24 PTMPY.
Correspondingly, PCMH clinics saw an increase in primary care office visits, with 163 more office visits PTMPY by 2013.
"Overall, the trends in the use suggest that increased access to primary care in PCMH clinics might have resulted in less frequent use of the ED," the study states.
Additional interviews conducted by the researchers with the heads of PCMH and non-PCMH clinics were used to gather information on organizational processes and operations.
Researchers, in additions to analyzing the claims data, also interviewed leaders of PCMH and non-PCMH clinics to learn more about their organizational processes and operations. Responses revealed that PCMH clinics offered extended and weekend hours, and a patient helpline.
PCMH clinics also tended to offer more disease management programs, and used health IT tools to improve clinical decision making.
Expanded accessibility, utilization of health IT, and a patient-centered approach to care coordination is the backbone of PCMH certification. Currently, in order to achieve and maintain PCMH recognition, providers should be familiar with how to use electronic health records for data-driven care, and must also develop expertise in population health management, patient engagement, chronic disease management, and team-based care.
But these competencies were put to the test in clinics that saw more than a 10 percent influx in SPDs, according to the study. Despite being able to reduce ED utilization among the general patient population, PCMH clinics that face a large number of complex users struggled to produce significant improvements.
"As expected, the PCMH clinics less affected by this transition had better results in reducing both ED and avoidable ED visits, whereas other PCMH clinics receiving more than 10 percent of SPDs had more consistent rates of ED use in the first year of the post-PCMH period and a minor dip in the second year," the study states.
"Our results suggest a potential crowding-out effect, where the introduction of a new population constrains resources that would otherwise be allocated to the existing non-SPD Medicaid beneficiaries."
Overall, the study suggests that the PCMH model may benefit safety net clinics with populations with high rates of emergency department use.
"Our results from a large urban Medicaid population suggest that a PCMH model in safety net practices can effectively reduce ED use and increase the use of office visits among Medicaid patients," the study states. "The findings support the effectiveness of the PCMH model that avoids ED use, while also revealing the potential limitations of the PCMH model in response to a sudden influx of high-need healthcare users."