Inflammatory Bowel Disease Care: “It Takes a Village”

Inflammatory bowel disease (IBD) is a complex, multifaceted condition, and patients often require a combination of behavioral, preventive and therapeutic resources in order to improve.

Traditional healthcare systems are neither organized nor incentivized to provide this coordinated spectrum of care, so treatment ends up being fragmented, ineffective and costly, frustrating patients, caregivers and insurers.

The IBD patient-centered medical home is a new and novel collaborative approach to the problem, pairing patients with a multispecialty team of healthcare providers who emphasize preventive care and nutrition and treat co-existing pain and psychological issues.

One of the IBD medical home’s architects, Miguel Regueiro, MD, Chair of Cleveland Clinic Digestive Disease & Surgery Institute’s Department of Gastroenterology, Hepatology and Nutrition, described its key components and benefits in a lecture at the American College of Gastroenterology’s (ACG) 2019 annual scientific meeting.

“About half of our patients with IBD do well once their disease is treated, but for the other half, the IBD is not the only thing that is driving their healthcare utilization,” Dr. Regueiro explains. “With the medical home, our team goes beyond focusing on the disease itself and looks at whole-person care. We offer patients one-stop shopping for their health.”

In his ACG lecture, titled “The IBD Medical Home and Neighborhood: It Takes a Village,” Dr. Regueiro outlined the elements of a patient-centered medical home and how it differs from the traditional IBD center of excellence, which is built around medical providers. He described the emerging concept of medical neighborhoods, which include primary care providers and can have a positive, broader impact on population health, not just on individuals.

A real-life example

Although new, the medical home model already is demonstrating that it can improve quality of life, decrease emergency department visits and hospitalizations, and should reduce the total cost of care. Dr. Regueiro provided an example from a Cleveland Clinic case.

“Our patient had Crohn’s disease that objective testing showed was in remission on biologic therapy,” he says. “But she made many visits to the emergency room for chronic pain and was having a difficult time paying her bills and keeping a job. She was taking opioids regularly and was a high utilizer of care who had undergone many CT scans.”

In the course of a year after joining Cleveland Clinic’s IBD medical home, the woman was able to discontinue opioid use and reduce her emergency room usage. Her depression eased and she was able to get a job. “Crohn’s disease was not this patient’s primary problem, and focusing on it missed the point that she had another problem — opioid dependence — that was causing her to seek medical attention,” says Dr. Regueiro.

Champions and secret sauce

The medical home approach has been employed for other chronic conditions, but the “secret sauce” in every application of the concept, as Dr. Regueiro sees it, is the team. The medical home caregivers from multiple specialties focus on treating the whole person and combine psychosocial care, nutrition, wellness, prevention, and the mind-body interface.

At Cleveland Clinic, the gastroenterologist is the principal provider or “champion” for a cohort of IBD patients. He or she is responsible for coordinating and managing this population’s healthcare while placing each patient at the center of the “medical universe.” That universe includes advanced practice providers (who are trained to make routine IBD care decisions, provide basic primary care and coordinate treatment with the gastroenterologist), nurse coordinators, schedulers, social workers, psychologists, colorectal surgeons, pain specialists, pharmacists, dietitians and more. Also key to the approach are a payer or health plan with an interest in specialty population-based chronic care willing to partner with the provider, and prespecified goals and measures of success.

Extending the neighborhood’s reach

Cleveland Clinic is using digital technology to make office visits more convenient for IBD patients, and to extend the medical home to primary care physicians and a broader geographic population — or “neighborhood” — of gastroenterology practices. Many patients travel long distances to receive IBD care at Cleveland Clinic, but now, after their first in-person visit, they often subsequently can have telemedicine interactions with the healthcare team.

“During a virtual visit, I sit at a computer, see the patient on my screen while viewing their electronic medical record on another screen, and spend 30 minutes discussing their problems, assessing their medications and reviewing their test results,” says Dr. Regueiro. “We essentially do an office visit wherever they can take the video call — at home, school or work. It’s revolutionizing the way we deliver care.”

Primary care physicians who have a question about their IBD patient can also “curbside consult” with Cleveland Clinic’s IBD medical home providers using an e-consult through the institution’s electronic medical record (EMR) system. The EMR also includes a registry of all IBD patients seen in the gastroenterology department, which allows physicians to aggregate data and identify patterns of care.

“The registry allows us to track data on hospitalizations and ER visits in real time,” says Dr. Regueiro. “That can help us spot care gaps, identify patients who need to be in the medical home, and ensure that we’re providing value-based care.”

Scaling up

Looking to the future of the IBD medical home and neighborhood, Dr. Regueiro foresees applications and benefits of the concept growing.

“At Cleveland Clinic, we view digital technology as a platform by which we can connect and scale to more patients and providers across the country and, eventually, internationally,” he says. “The medical home is in its nascent phase, but we hope over the long term that it will save health care costs and we will be evaluating that.”