glo & karen
Dr. Glorimar Medina-Rivera, executive vice president and administrator, Ambulatory Care Services at Harris Health, left, and Karen Tseng, senior vice president, Population Health Integration at Harris Health.
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National Recognition Highlights Success of ‘Medical Home’ Program at Harris Health

National Recognition Highlights Success of ‘Medical Home’ Program at Harris Health

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Nearly 108,000 patients at Harris Health System who use its medical home model of care are substantially healthier than non-participants — showing better control of diabetes, lower blood pressure and greater success at screening for flu, colorectal cancer and efforts to quit smoking.

Recently, Harris Health received recertification of 13 clinical sites (bringing its current total to 26 locations) as Patient-Centered Medical Home sites by the National Committee for Quality Assurance. It was nearly a decade ago that Harris Health became the first healthcare system in Houston to receive medical home designations.

“The Patient Centered Medical Home is a model of care that emphasizes comprehensive, coordinated and accessible care,” says Dr. Glorimar Medina-Rivera, executive vice president and administrator, Ambulatory Care Services, Harris Health. “Our goal is to help the residents of Harris County lead healthy lives and part of our job is to facilitate access to that full continuum of services. The NCQA recertification of our centers as medical homes validates the excellent care delivered to our patients.”

Patients in Harris Health’s medical homes receive all-in-one-location services like primary care, nutrition, laboratory, education and pharmacy from an assigned team of doctors, nurses, pharmacists and patient educators. For a patient to be in a medical home, he or she must have an assigned Harris Health primary care physician and at least two primary care visits within an 18-month period.

Harris Health wants to encourage more patients to enroll in medical homes because these patients stay more engaged with their primary care teams. Harris Health’s Population Health Integration team expanded the medical home model by adding resources that tackle patients’ top health-related social needs such as food insecurity, lack of transportation or poor health literacy.

“The medical home model is the foundation of an integrated, coordinated approach to health — whether improving transitions of care within the medical sector or improving coordination of care across the medical and social services sectors,” says Karen Tseng, senior vice president, Population Health Integration, Harris Health.

The results of medical home care are dramatic. Patients with diabetes show a lower rate (29 percent) of uncontrolled diabetes levels compared to non-participants who had a 40 point higher rate of uncontrolled diabetes. Patients who have uncontrolled diabetes are sicker and prone to severe nerve damage, kidney failure, loss of vision, and life-threatening conditions like stroke and heart disease.

In the past year, more than 1,000 patients in Harris Health’s medical home program have managed to lower hemoglobin A1c levels (average 3-month measure of blood sugar) from 9 percent (uncontrolled levels) to under 7 percent (controlled levels), says Dr. Mohammad Zare, chief of staff, Ambulatory Care Services, Harris Health, and associate professor and vice chair, Family and Community Medicine, McGovern Medical School at UTHealth in Houston.

“About a year ago, we challenged ourselves to raise our national quality benchmark to 75 percent from 50 percent, and that meant vaccinating more adults and children, providing more cancer screenings and improving outcomes for chronic disease,” he adds.

Additionally, 62 percent of medical home patients posted blood pressure levels within recommended national guidelines compared to 51 percent for non-program users. These patients also posted high preventive rates for several health conditions: 78 percent for diabetic foot exams, 67 percent for colorectal cancer screenings, 65 percent for influenza screenings and 49 percent for mental health (depression) screenings. In the area of diabetic foot screening, non-medical home patients had a 38 percent screening rate — a 40 point difference compared to medical home patients.

Medical homes are part of a national trend to restructure highly fragmented healthcare. The National Committee for Quality Assurance, a private, independent non-profit organization, surveys medical home sites and holds healthcare organizations clinically and fiscally accountable for patients’ health status and quality of care.

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