The state’s largest experiment in primary care innovation is showing how teamwork and smart data can improve patient care and reduce costs

By Susan Hagen

When Pedro Puron became a patient at Unity Internal Medicine at Cornerstone in January 2016, his diabetes was so out of control that his physician warned him bluntly it was “guaranteed something will happen to you” unless he started to take his health seriously.

Even so, when Puron began to work with the practice’s new care manager, Susan Marrone, he was skeptical. “I’m talking to this lady, and I’m thinking, ‘Oh man, now she wants me to do this, she wants me to do that.’”

Puron, who at the time weighed more than 350 pounds, was astonished at the small portion sizes Marrone recommended, particularly for a guy his size. Then she told him that for his favorite fruit, oranges, the ideal serving size should be not more than a half an orange, because of the fruit’s high sugar content. 

“I’m looking at this lady, and I’m thinking, ‘Is she crazy?’” he recalled, laughing.

But his care manager persisted with skilled medical assistance, weekly phone calls and nonjudgmental encouragement. “She was my mentor,” said Puron; she taught him to read food labels, educated him about diabetes and leveled with him about the devastating consequences of the disease.

That ongoing coaching paid off. Puron’s dangerously high blood sugar is now in check, and he has lost 50 pounds. “I’m feeling better. I’m looking better. I’m happier, that’s for sure,” he said. At the same time, this extraordinary approach to care is saving money by preventing expensive medical complications.

Puron’s experience is part of a behind-the-scenes transformation in health care delivery that has been underway in Monroe and five other Finger Lakes counties for the past four years. Sixty five primary care practices—about a third of the region’s primary care providers—have partnered with Finger Lakes Health Systems Agency on an uncharted journey to make our medical system as good at preventing medical emergencies as it is at treating them. 

Funded through the agency’s $26.6 million Center for Medicare and Medicaid Innovation award – the nation’s largest such grant in 2012 – the program trains medical practices to use teamwork and care management to keep patients healthy. It also uses electronic clinical data to track results and drive improvement. As the initiative wraps up, results show that the tandem transformation is making a real difference in people’s lives. Patients who worked with care managers have shown marked improvement in the management of such chronic diseases as high blood pressure and diabetes. Even more impressive, their hospital admissions have dropped more than 50 percent.

For Puron, the program’s new approach included having his care manager help him transition to insulin by communicating back and forth between Puron and his physician to adjust medication levels. “If it wasn’t for her calling once a week, I don’t think I would have gotten anywhere,” said Puron. “You have to have someone pushing you in a good way.”

From tennis to playing basketball

That focus on personal relationships is the bedrock of team-based care, said Michelle Casey, the principal investigator for the initiative and chief program officer for Finger Lakes Health Systems Agency. “It’s about how you interact with patients, and it’s also about how you interact with each other as a health care team, how you organize the work, how people communicate in the practice.”

To build those trusting relationships among colleagues, agency consultants worked with more than 1,200 physicians, nurses, care managers and other office staff, nurturing leadership skills and helping practices establish structures that encourage sharing and improve group dynamics. The initiative’s “morning huddles” provided an opportunity for staff to gather before patients arrive to review who is scheduled, what special needs they may have and other updates. Off-site “learning collaboratives” offered opportunities to see how other practices were solving problems. Monthly in-house meetings allowed staff to step back from daily demands and tackle larger challenges by drawing on insights from everyone on staff.

In recent monthly staff meetings at Shortsville Family Practice, for example, their team reviewed the data coming out of their electronic medical records showing that only about 40 percent of their patients who were 50 or older had gotten the recommended screening for colon cancer, the second leading cause of cancer death in the United States.

“We felt we were missing something,” said Rose Caparulo, care manager for the UR Medicine Thompson Health practice. They challenged themselves to rethink what role each staff member could play in encouraging their patients to follow through on the lifesaving procedure.

Together the team developed a game plan that begins before the patient even walks in the door, when the nurse checks the electronic medical record to see who needs a colonoscopy and flags their file. The doctor then educates the patient on risks and works to alleviate fears; the care manager addresses barriers, such as lack of transportation; and finally, so that nothing is left to chance, the receptionist schedules the appointment with the specialist before the patient leaves the office. The group even commissioned a poster for the exam rooms to remind patients about colon cancer screenings while they are waiting.

The result? In less than three months, Shortsville Family Practice’s rate for colonoscopies rose to 58 percent.

It takes a team to get these numbers going. It’s not just one person,” said Caparulo. “Between the receptionist, provider, nurses and care manager, the patient is really in a good place here at Shortsville.”

Research confirms that a team approach to care improves patient outcomes. The program found it also improved staff satisfaction, giving physicians the support they need to address more complex challenges, like behavior change or environmental problems, which are beyond the scope of the traditional 15-minute doctor visit.

But building such a collaborative culture takes commitment and change. “Becoming a team is like moving from tennis to playing basketball,” explained Casey. “You are not going to get results in basketball if you are playing by yourself. This new approach to patient care requires a whole different set of skills.”

Are we winning yet?

To measure progress, the grant provided technical assistance to help staff pull data from their electronic medical records, allowing them to see for the first time how their patients were doing as a group, not just as individuals. And, like the low colonoscopy rates at Shortsville, just seeing those numbers helped health care workers identify ways to improve care.

“The initiative helped us refocus and define ways of extracting data using query systems, massaging it in a different way, and then subsequently creating reports and graphs to help us identify issues concerning certain populations,” explained Andrea Plain, office manager for Internal Medicine of Brighton. 

Plain said one graph showing the change in blood sugar levels, a marker called HbA1c, convinced staff how important it was to track their interventions. The graph revealed that over 90 percent of the patients with diabetes who worked closely with a care manager and the practice team over a six-month period showed improved blood sugar control.

Seeing that dramatic success in graphical form, Plain said, was “kind of revolutionary” and led her to create an entire data wall at the practice, tracking progress on multiple metrics from diabetic patient LDL results to vaccination rates. Plain said those reports sometimes revealed challenges that caused staff to eagerly check the monthly updates.

“They’d be waiting to see this month’s new graph and say, ‘Ah, did we do better this past month?’” she said.

“The data was, for the most part, eye opening,” said Plain. “Doctors, nurses and other staff assume that if you take care of individual people, then the group will take care of itself.” But the data sometimes proves otherwise, she said. Not all patients will take their medications, go to the lab or do what you’ve asked them to do. “The data is what helps catch some of those issues.”

An ounce of prevention

Data can also catch people who haven’t made it to the office, but should have. More and more, research points to the advantage of seeing patients before they fall ill or end up in the emergency room. The theory is that screening for diseases like breast and colon cancer and providing care management for patients with chronic disease will save money and improve care by finding problems early when they are easier and less expensive to treat.

But does the theory pan out in real life? To answer that question, Finger Lakes Health Systems Agency made sure that the primary care offices in the initiative were representative of the whole region, with practices from suburban, urban and rural areas, from affluent as well as high poverty neighborhoods, and from large hospital systems and private practices. And the agency tracked results, collecting data on clinical measures and hospital visits for patients during the six months before and after being assigned to one of the 89 care managers provided by the grant.

They found that as a group, those patients experienced improvement in blood glucose, blood pressure and LDL cholesterol, clinical markers for diabetes, high blood pressure and heart disease. Hospital admissions also declined by more than 50 percent and emergency room visits dropped more than 40 percent for those receiving health coaching.

“That’s not just good, that’s amazing,” Casey announced to applause at the initiative’s last learning collaborative in June.

“Anybody can end up at the ED once,” Casey later explained. “But if you’ve ended up in the emergency department two times in a few months, you are way more likely to repeat.” Frequent trips to the emergency department often signal a deeper problem such as chronic disease, addiction or homelessness.

“We helped providers identify their so-called ‘frequent flyers’ and gave them the tools for addressing those underlying issues,” said Casey, noting that care management does cost the health care system money, but keeping just one person out of the emergency room or hospital over and over saves thousands.

Paying for wellness going forward

That smarter approach to spending will become increasingly important as state and federal governments shift from paying for procedures to paying for outcomes. By 2018, Medicare and Medicaid plan to base 85 percent of payments for health care on such measures as the cost of care, quality improvement efforts and the health outcomes of patients over the year. Commercial payers are expected to follow suit, explained Dr. Thomas Mahoney, chief medical officer for Finger Lakes Health Systems Agency.

For the average person, that change will hopefully translate into care givers being paid to provide services that improve health and well-being, but don’t necessarily involve the traditional office visit—like the weekly phone calls from Puron’s care manager that made all the difference.

“For someone with diabetes, the doctor’s office needs to be concerned about how they are doing on an ongoing basis, even when they are not calling to make an appointment,” Dr. Mahoney said.

For medical practices in the Finger Lakes region, this new way of paying for care should be a boon as well. “We are entering this new era with a head start,” said Dr. Mahoney. Going forward, all practices will be required to use data, teamwork and care management.

In fact, the region increasingly has been recognized for its success in transforming care delivery. New York State’s new innovation model was in part based on the lessons learned during this Finger Lakes health care initiative, and the federal government has funded a $48.5 million Practice Transformation Network, co-led by FLHSA and New York eHealth Collaborative, to share these approaches with 11,000 clinicians across New York State.

 “Although the grant is ending, this is really just the beginning,” said Dr. Mahoney.

CMS Acknowledgement and Disclaimer

The project described was supported by Cooperative Agreement Number 1C1CMS331063 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.