Here is another model of care. The medical home model has been around for a while, but this is an interesting way to put it into use. I know I enjoyed reading this article and I hope you will, too. With so much new technology and with health care reform in the works, we all need to get used to the idea of doing things very differently.
By Patricia Wolff
of The Northwestern
Jack Clarke had come to a crossroads of sorts. He had maxed out his options for oral medications to control his diabetes and his doctor suggested he switch to insulin injections to gain better control of his blood sugar.
Clarke, 65, wasn’t keen on the idea of injecting himself and asked Dr. Matthew Kraemer if he might try anything else. Kraemer suggested a weight loss of 30 pounds to help Clarke reach his goal of lower blood sugar and better health.
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That’s when the staff at Affinity Medical Group Internal Medicine, 1855 St. Koeller St., kicked into action, using the best tools in the department’s new Medical Home program to help Clarke reach his goals.
The Affinity Medical Home is a team approach uniting doctors, nurses and specialized staff including counselors in a new way as a patient’s personal allies for primary care. These highly skilled professionals get to know each patient, understanding every aspect of his or her health. They work together to treat the whole person – body, mind and soul. Patients are treated in one location for all their primary needs.
Kelly Blaskey, a registered nurse specialist, played an integral role in Clarke’s care. She began meeting with him for weekly weigh-ins and pep talks. They’d go over his food diary and to talk about dietary and exercise choices he could make between visits to keep him on the path to better health.
He started the visits and food diary in August.
“It has been very, very successful and helpful,” he said. “I’m about halfway there. My goal is one or two pounds a week.”
Blaskey spent time educating Clarke about his illness and ways to manage it. It helps tremendously, he said, to have the medical team at Affinity on his side.
“My goal is to live 35 more years,” said the retired corporate training manager for Oshkosh Corp. “With Dr. Kraemer’s care and his team’s, I’ll get there.”
Medical Home as a delivery system for primary care garnered national attention during the presidential campaign of Barack Obama when he held it up as a potentially viable part of the country’s overall effort to reform health care, said Sandra Schaffer, an advanced practice nurse practitioner at Affinity.
It combines two goals – reducing health care costs and expanding care. It goes a long way toward managing chronic diseases and conditions such as diabetes, high blood pressure and elevated cholesterol by being proactive instead of reactive, Kraemer said.
“As a physician it is very gratifying to know we’re actually giving better care. You can see the results in patients’ lab tests and general health,” he said.
Another positive result is fewer hospital admissions as potential health problems are caught earlier and rectified before they become serious, Schaffer said.
Medical Home goes a step further in treating the whole patient by providing teaching as well as counseling, two huge components to treating people with chronic health problems. “Symptoms can get lost in the whole continuum of care. Depression, for example, can go untreated because a lot of people with chronic illnesses won’t go to a behavioral specialist. Here they’ll get that care because it is more familiar, easier,” Schaffer said.
Affinity is seeking accreditation by the National Commission of Quality Assurance for its Medical Home, first of all to be recognized for achieving national guidelines that indicate a high standard of care, Kraemer said, but also for economic reasons. “It can mean a different reimbursement from insurance companies for being more proactive.”
The goal of Medical Home as a health care model is to create a less fragmented health care system by having primary care physicians or clinicians coordinate a patient’s health care. The system focuses on patients to make sure they are getting the care they need when they need it and to help them understand the importance of being compliant with their medications.
A team of about 15 at Affinity Medical Home, with Kraemer as the lead physician, along with physicians’ assistants and nurse practitioners, licensed practical nurses, patient service representatives and even social workers and counselors, work at Affinity’s internal medicine department in Oshkosh to make sure patients receive the care they need when they need it.
“The biggest change is the immediacy of getting in to see someone when I call needing help right away,” Clarke said. “Several years ago if I called for an appointment and felt I needed immediate attention I’d be sent to urgent care because Dr. Kraemer was booked solid. The urgent care people are very good but it’s not the same. When I call here the staff all know me.”
These days when Clarke calls, he is seen right away. He is not sent somewhere else for care. Clarke was impressed with the help he received from Schaffer earlier this year when he went in with what turned out to be shingles. She treated him immediately and referred him that same day to an eye specialist for other symptoms she felt needed immediate attention. That same day she scheduled a follow-up visit for two days later at Medical Home to check his progress.
The Medical Home concept has been around many years, but is relatively new in this area. Aurora offers it at its Kenosha site but has not yet launched it in Oshkosh. Affinity is one of the first health care systems in the country to implement it. It was launched at the Affinity Koeller Street site in Oshkosh in January and is offered also at Affinity Medical Group Family Practice in Kaukauna. Plans are to roll it out at all Affinity primary care clinics in the next year or two, Kraemer said.
“We work strongly as a team. Everyone has a say and all team members were hand picked for their assortment of skills. They step it up and push themselves with one goal in mind: the best possible product,” Schaffer said.
The entire team, beginning with the patient service representatives at the reception desk, is focused on each patient. Cross training makes it possible for all the staff to get to know patients. Amy Wilkinson said this is helpful especially if a nurse is out and she needs to step up to escort a patient to an exam room. She can’t do everything a nurse can, but she can get the ball rolling.
Members of the staff say the teamwork is key.
“It’s so much nicer when somebody is watching your back,” said Lori Mauritz, an LPN.
Patricia Wolff: (920) 426-6689 or firstname.lastname@example.org.
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