A team to design your care plan

North Idaho Health

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Dr. Terence Neff performs a wellness check on Gavin Houpt, 5, Tuesday during an appointment at Coeur d'Alene Pediatrics. Neff is had lead the way in the local Patient Centered Medical Home treatment movement.

"Sometime over the last 40 years, the practice of medicine became physician-centered," said Dr. Terence Neff, a board-certified pediatrician at Coeur d'Alene Pediatrics. "Now it's all about the physician and not the patient.

"Doctors work nine-to-five and it may take a patient from two weeks to two months to get in to see them. Also, primary care doctors no longer can keep track of the other physicians their patients are seeing, so it's become very fragmented medicine."

"No other industry would survive if a client called for an appointment to get help with their car - or their insurance or their finances - and was told, 'I can see you three weeks from tomorrow. However, it's all about my schedule, not yours. It's your privilege to come and see me,'" Neff added.

But, in the immortal words of Bob Dylan, " ... the times they are a-changin'."

There's a new healthcare delivery model out there that's catching on slowly but ever so surely in the medical community. Called Patient-Centered Medical Home (PCMH), its goals include administering better and more comprehensive patient care by using a team approach to halt the splintering of medical services.

Sound like the same old song? Well, guess again.

According to Dr. Joseph Abate, chief medical officer of Dirne Community Health Center, "The PCMH concept is that you build a (healthcare) team that can do a lot of things which can and should be done outside the office visit itself. For example, before the visit, the patient's chart can be checked for needed updating; appropriate literature can be handed out; referrals can be made to appropriate subspecialists and patient education can be offered.

"The provider will then be able to look at what has been completed by the advance team and read a work report from the team containing, among other things, recommendations of what the team thinks should be addressed by the provider."

PCMH certification doesn't come fast and easy. It took almost two years for Coeur d'Alene Pediatrics to become certified as a Level III PCMH - the highest level currently achievable.

"The concept of PCMH is to put the patient and the family first and to acknowledge the difficulties families have at obtaining medical care in a very fragmented and confusing environment," Neff said.

PCMH is also about offering help to those who feel unable to run their complex medical lives without leaning heavily on an already time-challenged primary care physician.

"We have an older population now," Abate said. "We have patients with multiple chronic diseases and each chronic disease may require three to four different medications. So now into your office walks an 80-year old with six chronic medical conditions, 18 medications, 8 subspecialists and you've got all of 20 minutes to deal with it."

So here's another present-day scenario: You've been seeing Dr. X for several visits and you want to make an appointment with her for next week. You are told she's already overbooked, but they can get you an appointment with her nurse practitioner, whom you've never met. Now, in addition to your existing problems you can add a new one - anxiety.

With PCMH, Dr. X's nurse practitioner, physician assistant, RN and medical assistant would all already be part of your patient-centered care team - your "medical home" as it were - and they would be folks to whom you'd previously been introduced and felt comfortable with.

Dr. Leanne Rousseau, a family and community medicine physician, has been implementing PCMH at Kootenai Family and Internal Medicine in Post Falls for more than a year.

"Our goal is to keep people out of the hospital and keep them as healthy as they can be," Rousseau said. "The first thing we ask a patient is what their goals are and what they think should be the first steps they take toward them. It's only after that that we draw up a care plan.

"For their initial visit, we try to bring in the nurse practitioner and other team members the patient may later be working with. Our RN, for instance, is doing the case management part.

"A really hot topic today is how we coordinate care. When I send someone to say, a specialist, I want the patient's feedback. From our perspective there are so many different systems - so many ways not to communicate with each other."

So where, you might ask, is your "medical home" located?

"'Medical home' is not a building," Neff said. "It is a family of professionals working with the patient to provide the best care possible. It is truly a transformation about how we practice medicine."

In the best of all possible worlds, when your primary care doctor is part of a PCMH practice, you should never again feel medically alienated. You should never have the sense you are foundering in a sea of unclear diagnoses, foggy medication directions, specialists whose specialties you don't understand or primary care physician teams who aren't reachable in an emergency.

"What PCMH means to our patients is they have a central location and a central family that knows their medicial condition," Neff said.

"When we make a referral, we make sure the necessary information concerning the patient's overall health is transmitted to the provider. Then we follow up with the family as well as the provider. We need that provider's report to know what's happening with our patients.

"Who are our patient liaisons? They're our referral personnel who make sure the appropriate information gets to the referring provider. There's also a patient advocate who will call and track everything and make sure the patient actually shows up at the appointment.

"Did you know that, currently, 40 percent of people referred to specialists never went? They just gave up because it was too confusing for them. I think that families truly appreciate a navigator's help through the healthcare system."

According to Rousseau: "Anybody we refer to, we try to make a part of our family. Various specialties - especially endocrinology, neurology and cardiology - are now looking at PCMH because they really see the value of coordinating with primary care. Primary care physicians were considered gatekeepers for a long time, but now we're part of a team."

When it comes to the role of the care coordinator in the PCMH model, this is the person who looks at the national standards for medical care and ensures that patients receive the medical care mandated by these guidelines. There is also, Neff said, a strong social service component of this work.

Often patient health is directly related to social environment. Neff said that for some people, having to take a day off from work in the middle of the week to see the doctor can mean the difference between eating and not eating that week.

"I think families truly appreciate a navigator to help them through the system," Neff said. "They may not truly understand all the services that happen behind the scenes for them, but they do understand that we're open until 8 p.m. and open Saturdays."

As the number of PCMH practices increases, patients will find more post-visit surveys in their home mailboxes. Don't automatically send these to shredder heaven when you receive them, Neff said. Let your physician know what worked for you and what didn't.

"The only way we can improve is to get that feedback," Neff said.

There is, of course, a financial side to PCMH. "When you look at the cost of medicine," Rousseau said, "what we're doing is important. We will never control our costs unless we have personal engagement with people and their health care."

The Centers for Disease Control calls PCMH, "an emerging health care delivery model that aims to provide quality health care that improves patient outcomes and reduces costs."

Start-up and maintenance costs for the program can, however, be expensive.

Neff said that currently the cost to his office for adding new employees to implement PCMH is approximately $100,000 per year. But he added that PCMH has been shown "without question to provide more efficient healthcare, decreased hospitalizations and more effective emergency room and urgent care use."

Because of this, Neff said several insurance companies are now starting to offer medical offices reimbursements to bring the system on board.

"The value of relationships and communication - it's what makes medicine so different from other pursuits," Abate said. "It's what overcomes. I would say that PCMH restores the relationship between patients and healthcare providers. You can't just improve what we do with medicine, you have to transform it.

"Doctors love their patients - it's the thing that makes you put up with all the other stuff."

he local building industry has finally hit a sweet spot - below the boom and above the bust.

From the building boom that peaked in 2005 to the nose dive into 2011, area builders say the steady rise in housing starts the past two years have landed the perfect happy medium.

"The boom isn't healthy because it's always followed with a bust," said Scott Krajack, estimating manager for Viking Construction. "We're having a nice, steady growth spurt - and at a comfortable pace."

Krajack said consumer confidence, helped by a flushing of the foreclosures the past two years, and low interest rates have fueled the rise of the market.


Viking's Cottage Grove, a gated community in Coeur d'Alene with homes starting at $189,968, capsulizes current industry, he said.

"We haven't finished the model home and we've already sold three homes in there and there's an offer on a fourth," Krajack said. "This project sat vacant three and four years ago."

Todd Stam of Aspen Homes said his company is also seeing a rise in the higher-end market.

"Eight of our projects are over $1 million," Stam said. "Last year at this time we had one of those. The market is healthy."

Stam said Aspen has sold two speculative, or "spec" homes, valued at more than $1 million this year. Spec homes are built on the speculation that someone will buy them when construction is finished.

"We hadn't sold one of those in four years, so that shows you people are shopping for higher value again," he said. "You couldn't sell a spec home a few years ago. When the spec market comes back, that's a good indicator that people are shopping."

Stam believes the momentum will carry over to the winter months - more so than previous years.

"We'll be digging this fall and expect to have 20 projects to work on all winter," Stam said. "Typically, we don't have that much."

He said the only question is how long the run can be sustained.

"There's a lot of new buildings going up, but there are still a lot of gun-shy developers," said Stam, referring to how some developers lost projects during the recession. "The inventory may dry up. There's not a lot of annexations going on and there could be a frantic frenzy to get more building lots in six months to two years. If that happens, it could turn to more of a seller's market than a buyer's market.

"There's already smaller builders that are scrambling to buy lots. If we'll have the inventory, we'll be in good shape. If not, it will get tricky."

Power in the numbers

Area city and county building departments report a dramatic rise in building permit numbers this year.

In Coeur d'Alene, through June, the latest stats available, there had been 181 permits for new single-family homes issued for the fiscal year compared to 88 last year at that time.

Commercial permits rose from five last year to 17 this year.

"Our current building permit numbers are running close to 2008, which was toward the end of the previous building boom," said Ed Wagner, Coeur d'Alene's building services director. "Normally we see a rise in either commercial or residential, not both as we are currently experiencing."

Wagner also expects construction activity to continue strong in the months ahead.

"We do not anticipate much of a building slowdown, if any, through the summer and into the winter months," he said.

In Post Falls, through July, 131 permits for new single-family homes had been issued compared to 93 last year at this time.

On the commercial side, five permits have been issued versus seven last year at this time.

"Overall, I think this year's numbers will equate to last year's," said Russell Cornell, Post Falls' building official. "Our residential new construction seems to have leveled off for the summer."

Kootenai County had issued 119 single-family home permits through July 31 vs. 78 at this time last year. New commercial building permits have fallen from 17 last year to six this year.

Rathdrum's single-family home permits this year (25) have already passed last year's year-end total (24).

Total year-to-date permit numbers hadn't been compiled by Hayden as of last week.

Krajack and Stam said housing starts for their construction companies are up about 25 percent from last year.

"This year we expect to have between 160 and 175 homes," Krajack said, adding that Viking's total last year was 120 and two years ago 80.

A 'Smart' project in Post Falls

Among the current building activity is a five-unit residential project on Fourth Street just east of Post Falls City Hall. It is a new vision for an old part of the city.

Being developed by Cathy Retallick of Coeur d'Alene, it is the first residential infill project with Smart Code zoning to be constructed in the city center. The Smart Code was adopted four years ago to allow for high-density development and create live-work areas.

The project includes two duplexes, a single-story home and covered parking in the back.

It is set back only about 10 feet from the sidewalk and 3 feet from the property lines to the sides.

Completion is slated for this fall.

"We are hopeful that the Retallick project will spur other residential infill projects in the city center area of Post Falls," said Hilary Anderson, the city's planning manager.

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