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Circling the Dome

Intensive Attention for High-Use Patients

Internist and preventive health care specialist Laura Sander examines Marcella Baker, who is enrolled in the Priority Access Primary Care pilot.

The figures are sobering: Just 5 percent of Medicaid patients account for 50 percent of the program’s expenditures nationwide.

A new pilot program, launched here in East Baltimore less than two years ago, is pushing to keep such patients out of the ED and the hospital by providing very intensive primary care services that are integrated with behavioral health care and social services.

The approach is working: Since the start of Priority Access Primary Care (PAPC), the 70 patients enrolled in the program have seen their ED visits drop by 30 percent and their hospital admissions by 41 percent.

Participating patients have “incredibly complex medical and psychosocial needs,” says internist Laura Sander, medical director of the PAPC pilot. So the behavioral health care component is key. “We have more patients with depression than with hypertension. Thus, we’re really focusing on mental health care alongside traditional primary care. For us, they’re inextricable,” she says.

When patients come to East Baltimore Medical Center for a primary care visit, they spend 45 minutes with Sander or nurse practitioner Kate Shockley, then another 45 minutes with licensed clinical professional counselor Laura Fukushima. The health care team also includes certified medical assistant Sherrell Byrd-Arthur, who serves as a “health navigator” to help patients negotiate the health system, and community health worker Brian Adams, who connects patients to community resources (applying for housing vouchers, for example) and coaches them in disease self-management.

Patients have direct access to their PAPC providers. They can call, text or video chat with them 24/7 for acute needs.

In addition, PAPC providers carve time out of every day for home visits. New program participants receive a home visit as part of their introduction to the program. Patients with chronic conditions will receive periodic visits to help with medication reconciliation. Those with acute needs will be treated in the home, if appropriate, or sent to the ED. All patients discharged from the hospital receive a home visit as well.

Patients see their providers frequently at the start of the program. “We work to meet patients where they are, to get to know them and then slowly build their confidence and trust to work on their larger health challenges,” says Sander.

Set to run through the end of 2016, PAPC is showing a 2-to-1 return on investment, says Sander: “We’re happy to say that by doing exactly what we set out to do, which is reconnect high-cost patients to primary care, we’ve improved their health and saved money.”

Watch a video: Internist Laura Sander explains the aims of the Priority Access Primary Care pilot program.