Two Springfield family practices are developing closer relationships with their chronically ill patients in an attempt to keep them healthier, happier and out of emergency rooms and hospitals, where the cost of care skyrockets.

The Springfield Center for Family Medicine, which has six physicians, and the Springfield Health Care Center, with four, are two of 75 practices in the Dayton-Cincinnati region and 500 nationwide in a demonstration project funded by the Center for Medicare and Medicaid Innovation.

The Center’s Comprehensive Primary Care Initiative encourages what’s called patient-centered care. The approach that has primary care practices, one, help patients stay on top of things like their diabetes and high blood pressure so they’re less likely to have problems; and, two, make sure those patients don’t fall between the cracks if they end up in the emergency department and need to be hospitalized, sent to rehabilitation, then end up needing in home care.

Explained Debbie Cox, office manager of Springfield Health Center: “The project is designed to hopefully show that this kind of care, which is more costly to deliver on the front end, is a fraction of the cost on the back end” by reducing illness and hospitalizations.

Dr. Peter Muir of the Springfield Center for Family Medicine said the project hopes to address a crucial demographic question: “How is health care going to work with an aging population (that has) more people with needs and fewer primary care providers?”

To encourage innovative answers, Medicare, through the Affordable Care Act, is reimbursing participating practices an additional $20 per patient in the first two years of the project and $15 in the third and fourth years.

In years three and four, the per patient boost disappears, but practices will split the savings they generate throughout their region with insurance providers.

Both Springfield practices have used the first-year extra reimbursements to do two things:

• Add nursing staff to help people control things like blood sugar and blood pressure levels, and to provide follow up care as patients move from care setting to care setting.

• Invest in the kind of information technology needed to get data from hospitals and other facilities, to analyze their patient load’s risks, and report to Medicare on progress toward program goals.

Cox said Springfield Health Care now has two nurses per doctor instead of one.

“Every visit we’re checking all of your medications. Every single visit we’re checking to make sure your screenings are up to date,” she said.

Both practices also have added a care coordinator, who is in charge both of working with patients to control their chronic problems and keeping on patients’ cases as they are treated at multiple places.

Kim Blackburn, care coordinator for Springfield Health Care Center, said her work involves building two branches of relationships. One is with patients, so she can find out what help they need in meeting their care goals; another is with professionals at each of the other organizations treating the same patients.

She’s seen progress on both fronts.

“We’ve had overwhelming response from patients who just can’t fathom their doctor would think enough of their care to have one person in charge,” she said.

Dr. Vipul Patel, also at Springfield Health Care, said that as nurses work with patients the patients “understand we care about them, and they do more (to help themselves) than if we were not communicating.”

Blackburn also said that people at hospitals, care centers and home facilities also seem “excited to work with us” in looking after patients in a better way when the opportunity is available.

Jennie Pontsler, Blackburn’s counterpart at Springfield Family Medicine, said meetings the program requires be held with emergency departments have opened her eyes to the problems other facilities face, an awareness needed to build a foundation for helping one another work with the patient.

Muir, who has used information technology for more than 20 years, said the IT power has helped the practice get access to patient records from other facilities and allowed doctors to access patient information readily on their Smart phones.

A program Muir created also produces a daily list of patients from the practice who made visits to emergency rooms or been admitted or released from Springfield Regional Medical Center or Mercy Hospital in Urbana.

That gives Pontsler her marching orders.

“I get the report in the morning. I call the patient. I check on them to see if they’re taking the right medications and how they’re feeling,” she said.

She also finds out whether the patient needs a follow up visit with the doctor or with a specialist, which she helps the patient to schedule.

Muir also has created a program that evaluates all the patients in the practice on the basis of 10-12 measures including lab results, kinds of medications, and age and risk factors. That helps the practice decide which are more likely to need special attention.

Dr. Patel said this kind of risk rating is crucial.

“If I can take care of (the highest risk) 10 percent of my patient population in a coordinated way, I should be able to cut down hospital admissions by 70-80 percent. By doing comprehensive care we can cut down the complications, cut down the admissions and readmissions to hospitals and cut down overall costs.”

At both practices, the pilot program remains a work in progress.

Muir said that while IT systems can be wonderful, “the expense of the equipment and the (fast) rate of change in both the equipment and (CPCI) requirements are very difficult for a practice. And it’s not what docs are good at.”

Cindy Brewer, office manager at Springfield Center for Family Management, said time management is becoming more important as meetings within the practice, with other providers and as part of the pilot program mount.

On the other, hand, Muir said, “what we’ve done in the past year would have taken three to five years” without the program’s help.

Patel said he is “more excited” about the program now than he was at the outset “because I know what we can do with this, how much better we can get and how much better care we can provide.”

Both practices are ready to gear up their patient advisory councils, which they hope to use to identify barriers to patient treatment.

Blackburn is excited, too, about having a consultant in to help solve one of the practical problems so many people face: How to eat more healthful foods on a limited budget.

“Your physician can’t take you to the grocery store,” she said, but a care coordinator can help gather the information needed to draw up a list.