Securing Patient-Centered Care Amid the COVID-19 Pandemic Disruption

by Debbie Reinheimer

| 4 min read

Older patient talking to his doctor
The 2020 coronavirus pandemic has changed our everyday lives, from going to work to doing errands and even interacting with friends and family. COVID-19 also has changed the way we provide and receive health care, including the most basic of health care standards – the office visit. In the early months of the coronavirus crisis, many doctor offices stopped in-person appointments and moved annual physicals and sick exams to telephone or video platforms. That created a challenge for physician practices to maintain care for patients, particularly patients with chronic conditions like COPD or diabetes who need regular, ongoing attention. Fortunately, the Blue Cross patient-centered medical home (PCMH) model provides a solid framework that primary care practices use to maintain patient outreach and care amid the COVID-19 disruption. The Blue Cross PCMH program began in 2008. It’s a systematic approach to providing care completely focused around the individualized needs of each patient.

The PCMH Framework for Coordinated Care

A PCMH practice offers each patient a care team comprised of those professionals most needed for that patient. For example, in addition to the physician, a patient with diabetes may have a dietitian, pharmacist and nurse care manager on their care team. “The care team, combined with care coordination processes, electronic medical records and digital alert systems, help the PCMH practice to maintain patient outreach and communication even while working remotely,” explains Amy McKenzie, M.D., MBA, medical director at Blue Cross Blue Shield of Michigan. PCMH practices have processes in place to track what tests and appointments patients need and remind patients to get them done. And PCMH practices are electronically connected to record systems that alert them when their patient has a test result or has visited the hospital or emergency department. So, the PCMH practice can quickly follow up and make sure their patient gets needed care. Many PCMH practices use nurse care managers who review patient medical records and reach out to those patients who need a test or check-up. During the coronavirus shut-down, care managers scheduled patient tests and exams and conducted telehealth visits to follow up with those who tested positive for COVID-19. “These capabilities are built into our PCMH model, and they helped practices provide continuity of care and seamless attention to patients,” said Dr. McKenzie. “During the pandemic, it has been important to engage and support our most at-risk members, so their conditions don’t advance to a point where they need emergency room or inpatient care.”

PCMH Designations Continue in 2020

This year, 4,644 primary care physicians in nearly 1,700 practices across Michigan earned Blue Cross PCMH designation. These practices are in 80 of Michigan’s 83 counties and combined they care for nearly 3 million Blue Cross members. Patients in these PCMH practices, when compared to non-PCMH practices, have lower rates of hospital stays and emergency visits, because they get the care they need from the practice before situations escalate and require higher levels of care. For example, this year PCMH practices compared to non-PCMH practices had:
  • 35.5% lower rate of adult ambulatory care-sensitive* inpatient discharges
  • 33.1% lower rate of adult primary care-sensitive** emergency department visits
  • 35.5% lower rate of adult readmissions to the hospital
  • 9.6% lower rate of high-tech radiology services for adults
  • 39.1% lower rate of pediatric primary care-sensitive** emergency department visits
  • 29% lower rate of overall pediatric emergency department visits
This year marks the first time that practices will earn two-year PCMH designations. After 12 years and continued growth of the program, the PCMH model has become the standard of practice in Michigan. PCMH designated PCPs have demonstrated years of providing high quality care. There’s no longer a need for yearly review. “The Blue Cross PCMH model is the cornerstone of our longstanding success in delivering a high-quality, high-value, affordable health care system for the people of Michigan,” said Dr. McKenzie. To find a PCMH primary care physician, go to “Advanced Search” in the Find a Doctor section on and select Patient-Centered Medical Home under “Quality Reports.” *Ambulatory care-sensitive conditions are those that shouldn’t require inpatient hospitalization if appropriately managed by a primary care physician. **Primary care-sensitive conditions are those that should be managed by a primary care physician so that an emergency department visit isn’t necessary. Related:
Photo credit: FG Trade

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