New Orleans grows into testing ground for medical homes

In the low-income Treme neighborhood of New Orleans, Anjali Niyogi, MD, makes her patients feel at home.

Three days a week, the internist treats area residents who come to the Tulane University Community Health Center at Covenant House, a clinic that has become a refuge for the uninsured and underserved.

"For a lot of patients who live in the neighborhood, we are the first stop for them. They get to know the doctors. They feel comfortable that they can call them at any point. It makes for easier physician-patient relations," she said.

The Tulane center is among more than 20 clinics in greater New Orleans reshaping primary care by introducing a medical home concept in neighborhood clinics that serve as havens for the needy. Charity Hospital once provided medical care to indigent patients with nowhere else to turn, but the facility closed when Hurricane Katrina walloped the region on Aug. 29, 2005.

Many medical leaders working to establish the new way of giving care said medical home settings will provide better coordinated primary care with specialist referrals and electronic medical records. And they believe this model of care is one solution to emergency department crowding fueled by patients who used Charity Hospital's ED for primary and other non-emergency care.

Physician organizations promoting medical homes in private practices nationwide are watching to see what happens. If the initiative succeeds in New Orleans, the model may be adopted more readily in other cities across the nation, experts said.

"It could be the phoenix -- that out of the ashes comes this new system of health care. If you can do it in New Orleans, where they have to rebuild the health care system, why can't you do it in other places that are not this far behind?" asked Anne Beal, MD, MPH, who has studied medical homes and is assistant vice president of the Commonwealth Fund, a health care policy organization in New York City.

National eye on the Crescent City

The federal government has set aside $100 million to restore access to primary care in greater New Orleans, and clinics will use the funds to advance medical home efforts, officials said. Some health care system redesign groups, which include physicians and area leaders, also are promoting medical homes to improve access to care and give patients a primary care base.

"What we want to do is have a network of publicly sponsored clinics where all their care would be coordinated," said New Orleans pediatrician Floyd Buras, MD, former president of the Louisiana State Medical Society and a board member of the Coalition of Leaders for Louisiana Healthcare, which supports the medical home concept.

But not everyone thinks the plan is enough. Some New Orleans residents want Charity Hospital reopened instead of replacing it with a new hospital in 2012. And some physicians fear that a lack of specialists, many of whom left after Katrina, will prompt primary care clinics to refer patients to emergency departments.

"I totally support having clinics around the city, but to go to the next step and make it a true medical home with multidisciplinary services, I don't see that happening. There's just not enough doctors to go around," said James Moises, MD, director of the Tulane University Hospital ED and immediate past president of the Louisiana chapter of the American College of Emergency Physicians. "I'm not trying to be pessimistic. I'm just trying to be realistic."

Meanwhile, national medical leaders are watching to see how the system develops. "They have a tremendous opportunity. They're building from scratch," said Rick Kellerman, MD, who is president of the American Academy of Family Physicians and practices in Wichita, Kan. "This is how you would build a medical home from the ground up."

In March, the AAFP, American College of Physicians, American Academy of Pediatrics and American Osteopathic Assn. issued joint principles of a patient-centered medical home. Those principles include a personal physician who provides first contact and continuous care, coordinated care across the health system, utilization of information technology and enhanced care through systems such as open scheduling.

American Medical Association policy supports "the concept of partnerships between primary care physicians and patients to coordinate access to all needed medical services and consultations (a 'medical home') for all patients."

In 2006, the AAFP launched a national demonstration project of TransforMED, an $8 million practice redesign initiative, with 36 practices integrating aspects of the medical home.

"Everybody is interested in this, but we still feel like we're at the very early part of it," said Joel Levine, MD, chair of the ACP Board of Regents and a teacher at the University of Colorado School of Medicine.

In New Orleans, some neighborhood clinics and health care redesign groups are using the joint principles as their guide. Local leaders hope private practices adopt the medical home concept, too.

Started shortly after Katrina by a group of physicians with little more than a box of supplies and a card table, the Tulane University Community Health Center at Covenant House has embraced the philosophy. Patients are assigned a primary care physician who leads their medical home team. Care is coordinated through electronic health records.

The clinic welcomes walk-in patients and offers extended hours two days a week. More than 3,200 patients, about 90% of them uninsured, consider the clinic their home.

"The point is patients can get in to see you when they need to," said Karen B. DeSalvo, MD, MPH, MSc, the clinic's executive director and chief of general internal medicine and geriatrics at Tulane University School of Medicine. She also chairs the medical home committee for the Louisiana Health Care Quality Forum, a group designed to help reform health care.

St. Charles Community Health Center is another New Orleans facility hoping to rebuild health care for the underserved and uninsured through neighborhood clinics. The center, opened in 2002, has EMRs, smoking cessation programs and open access, and serves some 13,000 patients, about 50% uninsured, through three sites and a mobile clinic.

"We consider ourselves a medical home. We are all about providing more than episodic care," said Mark Keiser, the center's CEO and executive director. "This medical home system of care is something we should try to achieve here."