Stacie Longwell Hill from Education to Practice, wrote an article for their website featuring Integrated Health Partners. Below is the article.

Beyond Checking Boxes to True Practice Transformation; Building Patient Centered Medical Homes in Battle Creek

Integrated Health Partners (IHP) of Battle Creek is a collaborative of more than 170 physicians in partnership with Bronson Battle Creek Hospital; created as a regional solution to address community health needs. Since the organization began in 1995, IHP has been a leader in bringing about change. Executive Director Ruth Clark, who has been there since the beginning of IHP, is a leader with a sense of adventure and is known for saying yes to new ideas. As a lean and nimble organization, IHP is making a difference in Battle Creek, taking on practice transformation and community health improvement.

By providing a strong central organization to support change in local practices, IHP has truly moved beyond meeting the requirements of Patient Centered Medical Homes (PCMH) to creating authentic transformation. Core values and practices make this possible.

  • Tracking data. Measuring patient metrics and evaluating results, along with evaluating trends keeps goals and successes for practices concrete and transparent.
  • Ongoing education. By offering Learning Collaboratives, they hold region wide regular meetings with a cohort of professionals from all disciplines to set goals, attending training sessions, share best practices and work toward better health outcomes. Practice Coaches and Care Managers work to offer education both in Learning Collaboratives and on site in the practices.
  • Organizational integrity. By being passionate about transformation, IHP constantly works closely with the practices to ensure compliance with the PCMH standards.

IHP started their patient centered medical home program (PCMH) Pathways to Health in 2006. They convened a group of employers, physicians, consumer groups, health plans, Health department, Commission on Aging, the Voces Hispanic community, and others. They looked at statistics around chronic illness and decided they needed a community approach. IHP convenes a leadership team advisory council that meets monthly to reviews data on chronic conditions, ER visits and other measures.

IHP also participates in the MiPCT program: Michigan Primary Care Transformation Project. MiPCT is a multi-payer supported pilot program intended to demonstrate the value of the Patient Centered Medical Home model of care. There are currently eleven practices affiliated with IHP that are MiPCT sites. MiPCT sites must be PCMH compliant for two years before being accepted as a MiPCT site. MiPCT financially supports a nurse Care Manager to assist the practice, allowing for increased case coordination and patient care.

Both the Pathways to Health and MiPCT programs have brought teamwork benefits to the practices and the patients. Physicians are spending less time on non-medical patient problems, allowing other staff with clinical knowledge to help identify community resources and get patients connected. This allows physicians to see more patients, making the best possible use of their time. By training all team members on their roles and the roles of others, the team is able to work more efficiently and is empowered to provide the best possible care.

The patient and community benefits are significant. The Pathways to Health 20011-12 pilot program focused on several chronic conditions as well as preventative services. The program initially included 13 teams from primary care and behavioral health. They have seen substantial improvements in measurements for BMI, depression screening, and self-management, as well as condition-specific metrics. For more details on their results, click here.

Making change isn’t always fast or easy. Having a physician to champion change and the support of the administration is crucial to the success of practice transformation. Practices face challenges of time constraints, staff turnover, data analysis, and have to be prepared for self-evaluation. However, with the support services provided by IHP, their physicians and partner practices are empowered to succeed, with the patients as the clear winners.

Have a practice transformation story to tell? Contact Stacie Longwell Hill at .