Physician-Led Clinics Offer Integrated, Coordinated Care to High-Risk Seniors Under Capitated Contracts, Leading to Strong Performance on Quality Metrics, Low Inpatient Use, and High Patient Satisfaction

Snapshot

Summary

ChenMed is a physician-led practice serving more than 20,000 Medicare-eligible seniors through 36 centers in six States. ChenMed offers integrated, coordinated care under capitated contracts primarily to high-risk, moderate- and low-income seniors enrolled in Medicare Advantage plans, as well as to seniors with traditional Medicare. Primary care physicians coordinate care with the help of a customized electronic medical record with built-in decision support, ensuring that patients receive all necessary services, most of which are available onsite. The care model features frequent, extended visits with primary care physicians; regular meetings of primary care and specialist physicians to discuss high-risk patients; hospitalists’ assistance in coordinating inpatient care; as-needed referrals to community-based agencies and other providers; bilingual providers; courtesy round-trip van transportation to appointments; the ability to handle walk-in patients daily; and a facility design that promotes communication among providers. To further facilitate such communication, patients receive an identification card with electronically embedded health information. The care model has generated strong performance in a variety of areas, including adherence to recommended screenings and care management processes, good blood glucose control among patients with diabetes, low use of inpatient services, 53 percent fewer hospital days than the regional average for seniors, and high patient satisfaction. The center’s onsite dispensing service has improved patient access to prescription medications, further improving health outcomes.

Evidence Rating(What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of access to medications after implementation of one component of the care model (onsite dispensing), along with post-implementation data on adherence to recommended preventive and care management services, blood glucose control among patients with diabetes, inpatient use rates (compared with the regional average), and patient satisfaction scores (compared with other providers and health plans).