Advanced Medical Teams: Improving Patient Health, Care Coordination at Iowa Health

The triple aim of healthcare reform has been a major focus in healthcare since the Patient Protection and Affordable Care Act passed in 2010. Hospitals and health systems across the country are beginning to take responsibility for the health of their patient population and look for ways to improve care quality and patient outcomes while lowering costs.

Des Moines-based Iowa Health System was one of the many systems seeking to work toward the triple aim. "We were looking to identify ways to strengthen the relationship between patients and…providers," explains Monique Reese, ARNP, vice president of clinical services and chief clinical officer of Iowa Health Home Care. From there, Iowa Health System found its solution in advanced medical teams.

The system launched its first advanced medical team pilots in Fort Dodge and Des Moines in June 2012. The pilot programs have since spread to reach six of the system's regions.

AMT basics

IHS uses data to determine which patients — usually those with chronic illnesses — could benefit from care by an advanced medical team. "We built a trigger list, based on the number of chronic diseases, medications and hospitalizations, and used…electronic health records to drive identification of patients who would benefit from the program," says Ms. Reese.

From there, there are two main important aspects that make AMTs successful.

Care navigators. Physicians work with care navigators — nurses with an expertise in community-based care — to make the foundation of an AMT. Specialists and other experts, like physical and occupational therapists and social workers, can be brought in on a patient-by-patient basis to work with the AMT when needed.

The care navigator plays a particularly critical role in the success of an AMT. James Meyer, DO, of Trimark Physicians Group in Fort Dodge, leads one of Iowa Health System's original AMT pilots with Janna Emick, the care navigator. "She has good organizational skills and acts as a liaison between myself, the office and the patients we target for AMT therapy," explains Dr. Meyer. Ms. Emick is a nurse with a home care and hospice background.

Ms. Reese agrees experienced care navigators are the lynchpin to AMT success. "They engage and empower patients and families," she says. "They [need to] have a strong base in health literacy…and motivational interviewing."

Care coordination. Once patients are identified, the care navigator or provider reaches out and provides personalized care in order to improve their health and wellbeing.

Dr. Meyer is a pulmonologist, so most of the patients he sees have chronic issues. However, the system works very much the same as it does in a primary care AMT. Dr. Meyer meets with patients individually in the office, and Ms. Emick reaches out to them as well, either in an in-office visit or on the phone, to ensure they are getting the services they need. "It can be as simple as going over medications, making sure they have resources for home health… [anything] we can do to help make sure they are well taken care of," Dr. Meyer says.


Increased care coordination and the use of team-based care have succeeded in improving the health of AMT patients. "We're seeing a large decrease in admissions to the hospital and emergency room," says Ms. Reese.

Dr. Meyer agrees. "Very anecdotally, a lot of the patients who used to be in the emergency department every month aren't there any longer," he says.

Beyond keeping patients healthy, the AMT program has been widely well-received by patients. "I think universally it's been positive," says Dr. Meyer. "They like the idea of having a care navigator that they can…contact with questions and know that someone is trying to be there…to keep them well."

"We've seen an overwhelming response of increased patient satisfaction and experience," agrees Ms. Reese. "[Patients] feel more connected to [their] primary care provider and resources in the community."

Therefore, Iowa Health System's team-based care has achieved what it set out to do: improve patient health outcomes and increase their engagement in care. Dr. Meyer summed it up well: "This is a very good implementation of healthcare. We're trying to keep patients healthy and at home and using care coordination to do so is really what our AMT [is] all about."

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Carondelet Health Network in Arizona Pursues Population Health Plan

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