What is the medical home in IBD?

Why inflammatory bowel disease?

Inflammatory bowel disease (IBD) is a costly and chronic medical condition that disproportionately affects a young population demographic. IBD patients have unique behavioral, preventative and therapeutic health care needs.1 Due to care complexity, management is often fragmented amongst multiple providers, frequently across health care systems with the burden of coordination, communication and follow-up left to the patient.

The targeted therapeutic armamentarium for IBD care is expanding, but expensive. Combined with the need for inpatient care, invasive testing, and surgical procedures, IBD care is costly. Recent estimates place the burden between $14-31 billion annually in the U.S. in both direct and indirect expenses.2,3 Consequently, IBD now ranks as one of the top five most costly gastrointestinal disorders.4

Patient-Centered medical homes

Patient-centered medical homes were first explored in pediatric care. Designed to coordinate care across providers including acute, chronic and preventative needs, the medical homes seek to increase patient satisfaction, improve clinical outcomes and reduce health care costs. Rising health care costs along with increased legislative support for value-based care including alternative models of health care delivery, have generated widespread interest in medical home models.

The IBD specialty medical home

Given the cost burden and unique patient population and care considerations of IBD, adaptation of the patient-centered medical home approach to specialty care is intriguing. The specialty medical home (SMH) is the concept to immerse the patient with a chronic specialty illness at the center of a patient-centric multidisciplinary health care delivery model, with the specialist serving as the principal care coordinator amongst the multiple providers.5 The IBD SMH has several core tenets of health care delivery: 1) multidisciplinary team-based care with a physician champion; 2) care coordination with individualized care plans; 3) outcome measures including clinical outcomes, quality measures, and costs; 4) incorporation and utilization of health care technology such as remote monitoring or telehealth; and 5) care access with open-access scheduling and clinic availability.6 From the patient perspective the medical home means a comprehensive, “wrap around”, whole-person care team for their medical needs.

The care team disciplines can include behavioral health (psychology and psychiatry), surgery, nutrition, social work and care coordinators. Such a system and team are designed to facilitate, streamline and address all of the individualized needs for that patient with minimal patient burden. Evaluation of individual factors driving disease activity, influencing access to care and altering risk profile for outcomes is critical to drafting individualized care plans. Such plans should be followed over time and modified as factors evolve. Incorporating advanced health care technology such as remote monitoring and telehealth, patients can stay engaged and connected between visits and across distances to ensure treatment plan execution and monitor for potential issues. Increased clinic accessibility allows for prompt evaluation of acute issues in the outpatient setting in order to minimize unplanned care to inpatient centers.

Partners in value

Caring for a population of patients with a specialty disease allows for partnership with payors. By aligning goals and incentives, more efficient, high-quality care is achievable and mutually beneficial. Such partnerships with a focus on value-based care invite novel reimbursement structures that transition away from fee-for-service models. The optimal payment structure for the SMH is not yet defined, but potential options include global capitated payments and shared risk shared savings. The IBD SMH system is adaptable and scalable and the exact tenets of an IBD SMH may evolve to meet population, payor, health care system or provider needs.

Does it work?

The first IBD SMH was designed and implemented in 2015. Partnering with an integrated payor-delivery system, the IBD SMH enrolled over 300 IBD patients over one year and demonstrated significant reductions in unplanned care (emergency department visits and hospitalizations) with concurrent improvements in disease activity, behavioral health and patient quality of life.7 While promising, there are still unanswered questions for the IBD SMH including cost savings, standard of care comparisons and long-term follow up. With an evolving health care landscape emphasizing cost reduction and quality improvement, the IBD specialty medical home offers a unique health care delivery model to improve patient experience and outcomes with potential cost savings. We are in the process of expanding the medical home concept to a medical neighborhood incorporating integrated primary care networks, and further exploration of the model that will help define the optimal care for IBD populations.

Key takeaways

  • The IBD specialty medical home is a novel, multidisciplinary approach to care coordination for individuals with IBD.
  • The key facets of the IBD specialty medical home are multidisciplinary care, care coordination, outcome measures, health care technology, and increased access.
  • Initial studies of the IBD specialty medical home demonstrate improved disease activity, quality of life, and reduction in health care utilization.
  • Exploring translation to other environments and disease states will allow model adaption and refinement.
  • Partnering with payors will allow for value-based care to expand towards disease population management.

Dr. Regueiro serves as a consultant and advisory boards for Abbvie, Janssen, UCB, Takeda, Miraca, Pfizer, Celgene, Amgen, and TARGET PharmaSolutions. He also receives research support from Abbvie, Janssen, and Takeda.

Dr. Click serves on the speakers’ bureau for Takeda, and consultant for TARGET PharmaSolutions.

References
1. Farraye F.A., Melmed G.Y., Lichtenstein G.R., Kane S.V. ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease. Am J Gastroentrol. 2017;112(2):241-258.
2. Cohen R.D., Yu A.P., Wu E.Q., Xie J, Mulani P.M., Chao J. Systematic review: the costs of ulcerative colitis in Western countries. Aliment Pharmacol Ther. 2010;31(7):693-707.
3. Cohen R.D., Yu A.P., Wu E.Q., Xie J, Mulani P.M., Chao J. The costs of Crohn’s disease in the United States and other Western countries: a systematic review. Curr Med Res Opin. 2008;24(2):319-328.
4. Sandler R.S., Everhart J.E., Donowitz M., et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122(5):1500-1511.
5. Regueiro M.D., McAnallen S.E., Greer J.B., Perkins S.E., Ramalingam S., Szigethy E. The inflammatory bowel disease specialty medical home: A new model of patient-centered care. Inflamm Bowel Dis. 2016;22(8):1971-1980.
6. Regueiro M.D., Click B., Holder D., Shrank W., McAnallen S., Szigethy E. Constructing an Inflammatory Bowel Disease Patient-Centered Medical Home. Clin Gastroenterol Hepatol. 2017;15(8):1148-1153.e1144.
7. Regueiro M.D., Click B., Anderson A., et al. Reduced unplanned care and disease activity and increased quality of life after patient enrollment in an Inflammatory Bowel Disease Medical Home. Clin Gastroenterol Hepatol. 2018;16(11):1777-1785.

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