MDNews - Central New York

patients better understand and manage their conditions. "We see people with chronic illnesses who require care for long periods of time," says Seth Kronenberg, MD, board-certified internal medicine physician with IACNY, Chief Physician Integration Officer at Crouse Hospital, and President of Crouse Medical Practice. "We cultivate solid, long- term relationships with our patients." Sports medicine, while more focused on lifestyle than illness, is another field in which IACNY physicians are developing lasting ties with their patients. "We practice nonoperative ortho- pedics and concussion care," says Paul Klawitter, MD, PhD, primary care sports medicine physician with IACNY and member of Crouse Hospital's Sports Medicine Program. "Whether caring for sprains, strains, fractures, exercise-induced asthma or degenerative conditions such as arthritis, we help patients maintain their active lifestyles." As a team of physicians who treat ongo- ing, often chronic conditions, IACNY naturally fits into the 21st-century model of patient care, the patient-centered medical home (PCMH). Defined by the Agency for Healthcare Research and Quality as a program offering comprehensive, coordi- nated care and accessible services, a PCMH demonstrates its commitment to patient- centered medicine through advanced methods, including electronic charting and tracking, evidence-based guidelines and rigorous performance standards. The National Committee for Quality Assurance designated IACNY as a PCMH in 2012, and the practice is presently a Level 3 PCMH, the highest such recognition. "We take a holistic approach to patient care," Dr. Kronenberg says. "We assist patients with socioeconomic issues, coor- dinate treatments with specialists, reduce medication errors and improve adherence, and draw on nonphysician resources, such as nurse managers and nurse practitioners, to help maintain ongoing patient contact." Expanding Horizons In 2010, IACNY aligned with Crouse Hospital, joining Crouse Medical Practice, an entity established to help facilitate and foster physician integration efforts through- out the Crouse care network. The move enhanced IACNY physicians' ability to reach across boundaries and serve patients. Two such connections are of particular importance to maintaining patient health and well-being: inpatient-outpatient transitions and patient-community inter- action. Both play a key role in population health management. Population health management seeks to accomplish the same aims across larger geographic areas and multiple physi- cian practices. Dr. Kronenberg, as Chief Physician Integration Officer at Crouse, focuses on the bridge-building vital to population health. "We are now much better positioned to integrate physicians around the inpatient- to-outpatient experience," he says. "Instead of seeing patients in random episodes, physicians can now interact and review the patients' needs across their disease states. Crouse Hospital's information technol- ogy resources are especially important, enabling us to share data as we work toward true collaboration between inpatient and outpatient settings." Even from the outpatient clinic or physician's office, it may be hard to track patients out into the community. Patients may not be able to afford medications or understand physicians' instructions. The patient-community transition, too, comes under the purview of population health management. "Our goal is to create a seamless transfer among settings, whether through coordinat- ing home visits, making reminder calls to patients or ensuring medication orders are communicated," Dr. Kronenberg says. "Physicians whose patients receive care at Crouse Hospital should feel confident we will notify them as soon as their patient is admitted, keep them updated and provide full reports on all active issues as soon as the patient is discharged into the community." At Crouse Hospital, patients respond positively to this model of population health management and the PCMH. The hospital is piloting an employee health management program, beginning with those employees with the most complex health needs (and their dependents). A nurse manager helps these patients obtain coordinated care and resources. Dr. Kronenberg notes that demand for coordinated care was strong from the outset. "We started where we would make the greatest impact," he says. "If you demon- strate value, people will see it. Most patients want help navigating a confusing system. They appreciate being educated about their health and gaining tools to manage their conditions." As the focus of medicine shifts toward population health, IACNY physicians and Crouse Hospital are finding ways to reduce costs and benefit patients at the same time. "This is the future of health care," Dr. Kronenberg says. "Keeping the patient out of the hospital is good for the patient, but — according to the old fee-for-service model — not necessarily in the hospital's best interest. We are looking at new reim- bursement models based on patients being the most important part of the picture. As we move from fee-for-service to population health management, we are using quality metrics to achieve cost savings and improve patient care throughout our community." To learn more about the specialty care avail- able through IACNY, visit www.iacny.com. ■ Dr. Kronenberg and IACNY cultivate long-term relationships with patients. M D N E W S . 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