JEANNA DUERSCHERL The Roanoke Times

Nurses Kristen Howell (from left) and Stephanie Goodman talk with nurse and care coordinator Vianney Marengo and Dr. Tim Beirne during a group huddle at Carilion Clinic Family Medicine's Vinton practice. At the end of each day, the team of doctors, nurses and coordinators gathers to discuss the next day's patients. The Vinton practice is the first of Carilion's primary care facilities to have the clinic's new patient management system in place.

JEANNA DUERSCHERL The Roanoke Times

Care coordinator and nurse Vianney Marengo (right) talks with Mercedes Rodriguez Mercado, a patient at Carilion Clinic's Parkway Vinton practice. Marengo is one of the practice's two care coordinators who follow up with patients after hospital discharges, keep track of their medications and discuss general medical issues.

At 83, Doris Jones was told for the first time she was diabetic.

The diagnosis came in October after a virus sent her to the doctor. Blood work showed her blood sugar levels were elevated.

With the diagnosis, Jones became one of the many patients at the Carilion Clinic Family Medicine -- Parkway Vinton practice with a chronic illness. Her condition subsequently put her at increased risk for a variety of health problems.

To manage the illness, Jones' physician prescribed insulin and then had her meet with a nurse trained to give extra attention to patients who have a chronic illness.

Susan Alexson is one of two care coordinators at the Vinton practice. She was hired in May, and her job is to keep track of patients, especially those with chronic illnesses. She makes sure vaccines, mammograms and other tests are up to date. And she answers a lot of questions.

"Sometimes it's hard to get ahold of your doctor, and I know if I call over there I'll get ahold of Susan," Jones said. "Personally I feel like it is in the interest of the patients. To me, it might be old-fashioned, but I find it comfortable knowing she is there."

Alexson and the other care coordinator spend their days making sure patients understand their conditions, medications and what community support is available. They ask, and answer, the questions that might be overlooked when the doctor tries to do it alone.

It's a role that previously did not exist in the practice and one that doctors say is making a big difference in the health of their patients and the time management of the practice.

"My patients are getting much more attention," said Dr. Henry Ivey, Jones' physician. "They have a much longer visit and they leave here with all kinds of extra information, things that we didn't give them before."

The addition of care coordinators to the Vinton practice is one of the tangible aspects of a new system the practice has put in place for managing patient care. The new system, which is called a "medical home," is something that Carilion is busy rolling out to all of its primary care practices in the region. So far, Vinton, which serves about 25,000 patients, is the only practice to have the system in place.

A national spotlight

The changes being made at the Vinton practice are attracting some national attention and being hailed as a model for improving care and lowering costs.

After enduring an onslaught of negative publicity surrounding Carilion's conversion to a clinic system, Carilion executives are welcoming the positive attention. They say the changes to primary care represent just one step in the process of transforming care to a clinic model.

"This is about moving away from the fragmentation of care," said Dr. Mark Werner, Carilion's chief medical officer.

By developing these primary care medical homes, Carilion has revamped how doctors, nurses and others in the office work to keep patients healthy. They're doing it through a variety of methods, including allowing patients to communicate with doctors through e-mail and emphasizing communication among practice staffs.

Earlier this month, two well-known figures in national health care came to Roanoke to see how Carilion has begun to implement its clinic model. Both said the trip was only the beginning of an ongoing relationship with Carilion.

"I'm really impressed with the leadership of Carilion," said Peggy O'Kane, president of the National Committee for Quality Assurance, a nonprofit that has been working since 1990 to move health care quality to the top of the national agenda.

The committee has already certified the Vinton practice as the first Level-3 Patient-Centered Medical Home in the state, a designation that is the highest level for the new system of care. To date, 2,350 physicians nationwide, including 14 physicians and three practices in Virginia, have been recognized by the organization as becoming medical homes.

O'Kane toured the Vinton practice and discussed how Carilion's efforts could be duplicated elsewhere.

"We go out and visit with practices of the future because it makes us feel good and it makes us inspired," O'Kane said.

That's a far cry from the previous attention that focused on Carilion's violation of antitrust laws in creating a potential monopoly that could drive up the cost of health care for area patients.

Another visitor, Dr. Elliott Fisher, said he is interested in Carilion because he believes the changes could improve care and reduce medical spending.

Fisher is a professor of medicine and director of the Center for Health Policy Research at the Dartmouth Institute for Health Care Policy and Clinical Practice. He is best known among his peers for studying national and regional health spending trends and how they correlate to health outcomes. He suggests that about 30 percent of current U.S. health care spending goes to services that provide no health benefit.

He is also a strong proponent of improving primary care to improve the entire health care system.

Carilion is working with Fisher as a test site for a pilot program on health care payment reform.

"We need a new model," Fisher told about 200 members of Carilion's medical staff during a presentation two weeks ago. "We need teams to manage populations."

He later added, "The redesign of primary care practices allows for tremendous opportunities."

The idea is to move medical payments away from the current fee-for-service model and toward one that rewards keeping patients healthy.

Under a new payment model the Vinton practice would be paid a number of ways, including earning a lump sum to care for patients.

"The reason for it is to cover all the extra services that the care coordinators are doing," said John Wendland, project manager for Carilion's medical home implementation. "It would also cover the use of the other resources, such as nutritionists and diabetes counseling."

Wendland said most likely payment reform will include combination of three methods: a lump sum known as capitation, the traditional fee-for-service and pay-for-performance. Pay-for-performance would mean the insurance company pays the physician a share of the savings incurred for reducing the amount of care needed by a patient. Fisher was quick to emphasize that this isn't achieved through rationing care, but rather by making sure a patient is treated properly the first time and remains healthy.

For now, however, Wendland said Carilion is having to subsidize the additional costs associated with the medical home, such as hiring the care coordinators, while still being paid through the traditional fee-for-service method.

A work in progress

As Carilion looks to work with insurance companies to rework how its doctors are paid, they are also monitoring the health outcomes of the patients who are being cared for under this new system.

The Vinton practice is collecting data to support the anecdotal accounts of improved patient outcomes. While it is still too early in the data tracking to see if patient health has improved, early indications are that the practice is doing a better job of making sure the patients are being properly followed by the doctors and nurses.

"I don't think this happened before because an office visit was too dissected and too rushed," said Alexson, the care coordinator. "A lot of individuals fell through the cracks."

As for Jones, she is quickly figuring out how to manage her diabetes. She now gives herself insulin four times a day and said she thinks meeting with Alexson has made a huge difference in her treatment.

"I feel like I have it under control," the Vinton woman said. "It's such a short time for me that I don't know what might happen tomorrow. I've learned that lesson. But I feel like with their help and my cooperating with them, I have a better chance of keeping a handle on it."

The early data also show a change.

In April, before the new system was in place, the body mass index of patients was measured only 73 percent of the time. By December the practice was calculating the measurement -- which is a tool for monitoring obesity -- for 94 percent of patients. Similarly the rates for mammogram screenings in females between 40 and 69 also increased since the new system was implemented. That went up from 38 percent to 55 percent.

"A lot of these things are just the beginning and they offer a lot of promise," Ivey said. "We'd be happy if this spread all over the country."