PAWTUCKET – When Brown University re-established its medical school in the 1960s, with the hospitals as the driver, pushing a reluctant Brown to do so, there was duchy system, with each of the hospitals receiving one or more departments as a prize, according to Dr. Jeffrey M. Borkan, physician in chief of the Department of Family Medicine at Memorial Hospital of Rhode Island, now part of the Care New England hospital network.

“Family medicine was given to Memorial,” Borkan said, in part because of its connection the community.

Over the next 40 years, Borkan continued, as the development of specialties grew in Rhode Island, Memorial was very much the place that kept the flame alive for primary care in Rhode Island.

“The metaphor I like to use is that [Memorial] was like a monastery during the Dark Ages, even if primary care wasn’t popular, the flame was kept alive,” Borkan told ConvergenceRI in a recent interview in his office. “Now, it’s like the Renaissance here, we’re able to expand into a system of care. And Care New England is interested in creating a system of care, not a group of hospitals.”

The deal to partner with Care New England closed on Sept. 2, and Borkan voiced enthusiasm for the change. “We’re thrilled to be part of Care New England.”

Today, Memorial is very much at the center of the health care evolution in patient-centric primary care in Rhode Island, serving as a teaching laboratory to develop innovative approaches to team-based care. Until recently, Borkan said, “I don’t think primary care was seen consistently as an economic advantage. But it is now.”

The expansion of the multi-payer R.I. Chronic Care Sustainability Initiative, which began as a pilot program and now has more than 250,000 patients – one quarter of state’s population – being served by practices that are patient-centered medical homes, places Rhode Island ahead of the curve in innovative health care delivery, according to Borkan.

When Memorial’s Family Medicine program first sought to become part of CSI-RI, there was at first some hesitation. Borkan said he countered the resistance by arguing the importance of training the next generation of doctors in new models of care.

“We don’t have, as a training site, the option of not being part of innovation and creating new models,” he explained. “We are responsible for the next generation of doctors, and if we don’t innovate here and begin to teach new models and be on the cutting edge of developing new models, then our graduates will not know how to practice in the new marketplace.”

A recent visit from a federal evaluator of the CSI-RI program provided some national perspective of how advanced Rhode Island is in its patient-centered medical home approach to primary care.

“We’re going from a small pilot to 25 percent with plans to go to 50 percent [of the state’s population],” Borkan said. “No other state is doing that. This is a huge breakthrough in what we’re doing here.”

The actual transformation of medical practices to patient-centered medical homes is not something that is easily accomplished, because each practice is different, according to Borkan. “There is not yet a gold standard or a recipe of how to do it,” he told ConvergenceRI. “At this point, expertise is being developed in the state in two places, here at Memorial and at Blue Cross & Blue Shield of Rhode Island.”

Memorial is working with CSI-RI to help transform new practices that join the initiative, mentoring the practices, Borkan continued. “It’s incredibly complicated and phenomenally difficult, because every practice is different and has its own dynamics.”

At some point, Borkan said, Rhode Island’s growing expertise in team practice may prove to be a marketable enterprise and a revenue source for Memorial – and for Rhode Island.

“Patient-centered medical homes are one piece of the puzzle,” Borkan said. “We have to go from patient-centered medical homes to patient-centered neighborhoods to Accountable Care Organizations. We have to involve specialists, hospitals, and nursing homes. As part of Care New England, we can actually do that. Eventually, it has to be all of Rhode Island, and all of the U.S.”

On the front lines of primary care, seeking out root causes
Dr. David Ashley, the medical director of Memorial’s Family Care Center, rattles off the numbers as he gives ConvergenceRI an impromptu tour of Center’s facilities. “There are about 10,000 patients, with some 39 residents, divided into three pods,” he said.

Ashley, who did his residency at Memorial, graduating from Brown Medical School in 1996, has been back working at the hospital for a little more than two years. He sees the work of the Family Care Center as changing the way that medicine is being practiced, looking at the root causes of problems, and not just treating illnesses.

“We want to keep people healthy,” Ashley said. “If we an get to the root causes of things, whether it’s bat poop in the belfry of someone’s house that’s [triggering asthma] and causing them to miss school and have multiple ER visits, then that’s the dimension we have to address.”

Ashley is currently collaborating with the Green & Healthy Homes Initiative to write a grant proposal to the Center for Medicaid & Medicare Innovation for a pilot project in Pawtucket and Central Falls to rehabilitate homes.

“They used to think that the root cause of asthma was asthma, and you treat that by taking your medicine,” he continued. “But if we can get to the source of problems, and not just with asthma, we can improve people’s health and save kejillions.”

The incentives for payments will totally change, Ashley continued, if progress continues to evolve with the development of Accountable Care Organizations.

One of the expansions now underway with the CSI-RI program is CSI-Kids, which is currently struggling with developing benchmarks for wellness for children. Did Ashley have a suggestion of what the metrics might be?

“I think if there was only one thing you could measure for kids and try to figure out the best way to invest your resources, it would probably be school absenteeism,” he said.

With primary care, Ashley continued, “You can’t leave the social and financial conditions out of the equation. School absenteeism is often a very early indicator for problems in life. We need to investigate the reason for those absences, to find out if there are problems at home, with transportation, with health.”

One of the frustrations for Ashley is the inaccessibility of data regarding the most expensive patients, data that the CEO of Neighborhood Health Plan of Rhode Island told Ashley he has but cannot share, for legal reasons. According to Ashley, the CEO said that he had the data of who the most expensive [Memorial] patients were, what their addresses were, and how much money has been spent on them in the last two years.

“if we can’t identify the patients, we can’t assign the nurse care managers to better manage these patients,” Ashley said. He said that one of his folks had called Medicaid in Rhode Island to ask for this data, and was told by whomever answered the phone that they would need to file a Freedom of Information Act request to do so.

Ashley said that if a legal way could be found to access this data from Neighborhood Health plan, it would help to better manage the most expensive patients, reducing costs, improving outcomes and help prove that patient-centered medical homes work. He acknowledged that some interventions would not work.

[Whle the Family Care Center has about 3,000 of its roughly 10,000 patents who have enrolled to be part of thre stat's health information exchange, Currentcare, it has been unable to send any continuity of care documents because of computer interface issues, according to Ashley.]

For Ashley, the new approach to patient-centric family is a much more satisfying way to practice medicine. Here in Rhode Island, Ashley continued, “The visionaries are in the right places. We got a great director of the R.I. Department of Health in Dr. Michael Fine. He gets it. And with Care New England, the CEO, Dennis Keeefe, he gets it, he knows it, he’s pushing for it." 

Ashley’s fear, he continued, “is that it is an experiment that may continue, because it’s going to be more expensive than just having an office and a doc and a secretary.”