Almost 500 patients sign up for coordinators
Beacon provider partners have signed up 463 patients so far with diabetes and other chronic conditions and matched them with care coordinators to help them manage their care. But Hawaii beacon is going a step further by figuring out patient needs beyond solely medical ones to create a care coordination neighborhood, Ross said.

As a result of a learning collaborative that took place during the summer among providers and community organization professionals, beacon participants chose one complex patient from each of the Big Island’s north, east and west regions to track over 30 days in ordeer to identify all the services these selected patients use, whether health or human services or transportation. They anticipate reporting at the end of this month on gaps that exist and brainstorm on how to bridge them, she said.

(Pictured above, at right: Hilo Medical Center, a beacon partner.)

For example, a patient may miss an appointment because the car broke down. The island county offers little public transportation because of the relative small population and isolation of communities, but there are services that could be tapped to assist them.

In the beginning it was difficult to schedule busy physicians and community professionals for conference calls to build a care coordination neighborhood, but after the first one and relationships were started, they were eager to share phone numbers with each other and meet at each other’s office. “It happened that organically,” Ross said. 

The relative isolation of the island and the sense of community lend itself to a care coordination neighborhood. “There is a need here, and that’s why this site was selected. Of all the places where we can apply some viable solutions, I think that’s part of why they looked at Hawaii Island. They saw a potential here for success,” Ross said.

Additionally all the right players are at the table, said Jessica Yamamoto, community engagement manager. “Aloha is a source of collaboration and people willing to talk story. Talk story can be different for everyone, but for me it is if you come, you share, we listen,” she said, referring to two cultural concepts of respect and welcome that run deep on the Big Island.

On the mainland, many of the physician practices and hospital partners in other beacon communities also compete with each other for patient business, said Melinda Nugent, beacon’s clinical program manager.

“We don’t have enough physicians on the island, and our hospitals are so far away from each other that there is not really a competitive nature,” Nugent added. “That lends itself to a collaborative environment,” Nugent added.

In another example of streamlining, the three island hospitals are using a tool called CarePass, in which they provide patients with simplified and standard information when they are discharged to smooth care transitions, Yamamoto said. The yellow form contains medication reconciliation medical issues, patient identifier and the clinicians the patient will see over the next week.

“Right now it’s a paper template. But once they are able to realize that it works, then the next step is to create technology alongside it,” she said.

Fostering patient-centered medical home
Hawaii beacon is also helping physicians to redesign their practices to a patient-centered medical home model. Currently, 19 physicians around the island have made significant progress through a guided process from TransforMed to better coordinate, plan and manage care and encourage patient involvement, Nugent said.

TransforMed online consultations, webinars and training covers change management, high-performing clinical teams and office workflow. TransforMed also gives physicians access to a website where they can compose questions about the model and receive answers and feedback from other practices.

The participating physicians also meet and collaborate for a day over practice redesign and decide what comes next.

“On the west side of the island in Kona, where we have really small practices, some just a single physician and one staff member, this gets them to see themselves together as a unified group instead of isolated practices,” she said.

One of the beacon partners, the National Kidney Foundation, has hired coaches to help physicians, such as with assignments they must complete or further explain material in the training webinars.

Hawaii beacon does not offer any incentives to physicians to encourage them to sign up to convert to a patient-centered medical home except the free help. “But they know reform is coming,” Nugent said. Also, Hawaii Medical Service Association, the major payer, is involved.

All of the beacon projects map to the patient and are coming together, Jendrysik said. “All of these tracks run in parallel and have their own pilots," he added. "But we’re going to see more of them coming together around the patient."