IBD Patient-Centered Medical Home Delivers Integrated Multidisciplinary Care to Patients

Model provides an all-inclusive service for patients with IBD

Managing patients with inflammatory bowel disease (IBD) can be challenging due to the complex nature of the disease and multiple comorbidities which often lead to the fragmentation of care between several different specialists. One solution being implemented to overcome these issues? The IBD patient-centered medical home.

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Patient-centered medical homes aim to overcome some of the problems associated with the fragmentation of care by providing integrated care, improving patient experience and reducing costs. Although medical homes have already demonstrated advantages when applied in a primary care setting, recent incentives have aimed to apply this model of care in patients with IBD and other chronic gastrointestinal (GI) conditions.

An integrated approach to IBD care

At Cleveland Clinic, Miguel Regueiro, MD, Chairman of the Department of Gastroenterology, Hepatology and Nutrition, is at the forefront of this effort.

“Delivery of integrated, high-quality, specialty medical care is at the heart of the IBD medical home at Cleveland Clinic,” he says. “Our comprehensive approach to care involves a team of providers comprised of gastroenterologists, surgeons, nutritionists, dietitians, nurses, nurse practitioners, and psychologists. And while the concept of a medical home is not new, Cleveland Clinic is ready to fully implement the model in the care of patients with IBD and the first with plans to expand into a medical neighborhood.”

According to Dr. Regueiro, the integrated health approach delivered in the scope of IBD medical home “reaches beyond the biological disease and captures 90 percent or more of the patient’s needs, whereas the standard approach that involves only a gastroenterologist has proven to only focus on the disease itself.”

In addition to being more rewarding for the healthcare provider, an integrated approach to care ensures a better experience for the patients and results in many practical benefits:

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Time savings. “This aspect is significant because the IBD home serves as a ‘one-stop shop’ for the patient,” explains Dr. Regueiro. “Instead of being referred around to see different providers, our patients can schedule appointments with a team of providers that can address their medical issues in a single appointment. This approach also facilitates communication about the care plan for each patient among different specialists.

Cost savings. As a result, this reduced number of appointments translates to substantial cost savings for both the patient and the health system, and the potential to decrease unplanned care.

Improved patient satisfaction. As far as tangible benefits for patients are concerned, Dr. Regueiro says he is already witnessing improved patient satisfaction and outcomes as a result of implementing the model. “We have observed improvements in the overall quality of life, as well as decreases in disease activity and prolonged effects of medications and surgical treatments,” he says. “Long-term, we’d also like to see improvements in school and work productivity, as well as a decreased rate of emergency room visits.”

Expanding the model — from IBD home to IBD neighborhood

Dr. Regueiro expects that an estimated 1,000 new patients will utilize Cleveland Clinic’s IBD medical home in any given year. This high volume of patients has prompted him and his colleagues to consider expanding the IBD medical home concept into a larger IBD neighborhood.

“Our efforts to improve the care of patients with IBD do not stop with IBD home,” he says.  “With the help of digital technology, we are now working on establishing the-first-of-its-kind IBD medical neighborhood — a larger population strategy that links primary health physicians and regional gastroenterologists who treat patients with IBD with an already existing Cleveland Clinic electronic platform.”

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According to Dr. Regueiro, the aim of IBD neighborhood is “to seamlessly link patients and providers across the network and leverage technology to deliver care in asynchronous and synchronous digital platforms.  The idea is to fully integrate primary care physicians with IBD specialists, to keep the patients in their communities, and try to limit unnecessary trips to the hospital.”

Dr. Regueiro is optimistic that the integrated healthcare model delivered in the scope of IBD medical home could have potential applications across a range of other diseases in the future.

“We are currently at the discussion phase of potentially implementing the medical home model to other diseases, for example, chronic liver disease and fatty liver disease,” he says. “But even outside of the GI disease space, a range of other chronic conditions could also benefit from this model including rheumatoid arthritis or multiple sclerosis, just to name a few.”