Aurora UW Medical Group's Implementation of a Medicaid Medical Home Pilot

Background: Aurora UW Medical Group (AUWMG) includes 12 clinics that serve patients across their lifespan within greater Milwaukee (WI). AUWMG is participating in a three-year pilot entitled the "Integrated Delivery System (IDS) Medicaid Medical Home Pilot". The pilot focuses on engaging patients to use their medical home for preventive care and to seek a primary care provider for episodic care and the management of on-going, chronic conditions instead of using emergency care. By helping patients recognize these clinics as their Medical Home, our goal is to positively impact their health outcomes by providing coordinated, systematic, compassionate care at the appropriate level. This care coordination involves the clinic, emergency departments and the Medicaid HMOS. Objective: To describe the design, implementation and evaluation of the integrated health care delivery model into three 3 different patient-centered medical homes within the same medical group. These clinics are diverse from each other geographically and they serve patients that vary by specialty, socio-demographically and by payor mix. Design and Participants: A prospective cohort of Medicaid HMO participants were evaluated for 9 months. This evaluation consisted of monitoring interventions that were designed to influence the clinical care management, the emergency department (ED) utilization and hospitalizations among this oftentimes transient patient population. Measurements: Data was obtained from the health care system's electronic medical records, the clinic's patient billing system and from the HMO's claims database to indicate clinical diagnoses and treatment, ED utilization and hospitalizations. Results: The standardization of their approach to addressing the overall health care coordination needs of patients in the three clinics has proven successful. As a result clinical care management scores have gone up and the ED utilizations are better coordinated. The improvement in collaborative, working relationships and resources among the care team of clinic, emergency department and HMO staff has contributed significantly to the current success of this medical home pilot. Conclusions: Aurora anticipates positive clinical outcomes and patient satisfaction due to the improvement of spectrum-wide care team coordination and communication with a patient-centered focus. Aurora and the HMOs are jointly utilizing clinical, technological and human resources to develop best practices for evidence-based standard of care; maintain access to care for clinical and behavioral health; and consistently evaluate progress and adjust practices and resources accordingly. As an accountable care organization this Medicaid medical home pilot is part of Aurora's journey to create care models for disease prevention and wellness across each patient's lifespan.