A Homegrown Connecticut Primary Care Model Gains National Attention

Story by Michael Lee-Murphy from Connecticut Magazine. 

Just a few years ago, Jose Torres was in rough shape. He weighed about 460 pounds, with elevated blood sugar levels. “My life was just going down,” Torres says. Torres fits the profile of someone who might be forgotten by the standard systems of health care. He has chronic health problems stemming from diabetes, and is insured under HUSKY Health, Connecticut’s Medicaid program. These days, Torres receives a battery of health care services that would be the envy of anyone, at any level of the American health care hierarchy.

In recent years, he says he has dropped 53 pounds and his blood sugar levels are stable and under control. He sees a nutritionist once a month, a nurse every three or four weeks, a podiatrist once or twice a year, and a chiropractor when he needs it — he has a lot of pain in the levator scapulae muscle in his neck. (“I even know what [the muscle] is, because I talked about what was bothering me,” he says.) All of these services are covered under Torres’ Medicaid insurance.

“If it wasn’t for these people, I’d probably be dead already,” the 45-year-old says. The people he’s referring to are the providers at a peculiar set of health care facilities in the state that has been gaining national attention. Community Health Center is a network of 15 primary care facilities throughout the state covering low-income and uninsured patients from nearly all of Connecticut’s 169 towns and cities.

“If it wasn’t for these people, I’d probably be dead already,” the 45-year-old says. The people he’s referring to are the providers at a peculiar set of health care facilities in the state that has been gaining national attention. Community Health Center is a network of 15 primary care facilities throughout the state covering low-income and uninsured patients from nearly all of Connecticut’s 169 towns and cities.

The insurance and health realities faced by a patient like Torres are not atypical. Torres is exactly the type of patient CHC takes as its starting point: those who might perhaps otherwise fall between the cracks of other, more common health care models, those people for whom health care is often a lurch from emergency room to emergency room, crisis by crisis. CHC instead asks a question. What happens when we redesign primary health care, valuing a preventative health care model for those segments of the population for whom — whether because of poverty, lack of access or chronic health problems — don’t typically receive quality health care?

Over the past four decades, CHC has crafted a holistic view of primary care that serves 145,000 people in Connecticut. The system incorporates notions of design, telecommunications developments, clinical research, new professional training models and even a dance studio.

Founded in Middletown in the early 1970s, the model developed by CHC has been so successful that this past summer it was chosen as one of 10 participants from across the U.S. to take part in a $55 million study conducted by the National Institutes of Health, branded as the All of Us Precision Medicine Initiative. The study is aimed at collecting a wealth of data to “improve our ability to prevent and treat disease based on individual differences in lifestyle, environment and genetics,” according to the NIH. The study hopes to collect data on 1 million participants throughout the country, which would make it one of the largest health studies in history. Apart from the study’s size, its scope is also larger than a typical medical study. “There’s a whole range of information that hasn’t been looked at before in a study,” says Mark Masselli, CHC’s founder and CEO. Traditionally, Masselli explains, medical studies take in clinical, diagnostic and insurance claim data to determine patterns and trends. The NIH study, he says, will also include data from the collection of blood and urine samples for DNA, as well as the wearable technology that is becoming increasingly common, measuring certain aspects of a participant’s lifestyle. The goal is to create a broad data set on a large number of patients from different parts of the country in order to understand the relationships between various biological or lifestyle factors and health.

For Masselli, who in his ponytail and sunglasses cuts an atypical figure for a health care executive, one of the biggest innovations CHC has undertaken is one of the most basic, that of design. On a tour of the CHC flagship facility in the North End of Middletown, Masselli says the design is guided by the adage, “what the eye sees, the heart feels.” He says 70 percent of CHC patients’ first interaction with the health center comes through their kiosk system, which resembles a self-service check-in kiosk at the airport. Upon checking in, the patient’s fully digitized medical records appear to a clinician, and based on what Masselli calls “preventative standards” that hover in the background and drive all care offered by CHC, other types of care are offered. You might come in because of back pain, but you’re also due for a physical, a teeth cleaning, a visit with a behavioral health specialist, and so on.

This integration of services through design innovations extends to what is perhaps the central innovation of CHC, the “pod system,” which is more reminiscent of the tech world than primary care. “No doctor has their own private office, no nurse has their private office. … We work as a team, actually in one big room. And we have electronic health records, and we communicate right with each other and we go down a hallway where our patients come,” Masselli says. 

In a more traditional primary care design, various types of care would be housed on different floors, or in different facilities, creating any number of figurative cracks along the way in which patients can get lost. In CHC, all of these types of care are grouped into pods, giving patients no opportunity to get lost along the way. 

According to Dr. Daren Anderson, who heads up the research and innovation arm of CHC, the Weitzman Institute, the pod system is simply a design reflection of the undergirding philosophy of team-based care. “It’s absolutely a model that’s being embraced and spread across the primary-care system,” he says. He points to several providers — such as national chain Iora Health, which doesn’t focus on underserved populations, as CHC does — that are adopting the team-based-care approach. Hospitals, Anderson notes, have traditionally been already required to adopt a “vigorous” team-based approach because of the nature of the care they provide, whereas the traditional primary-care model more resembles a single doctor in an office, doing everything. 

In the case of behavioral health, Masselli says there are two distinct benefits to having services housed under the same roof in the team based model: stigma and data. If the mental health services are housed on a separate floor or in a separate building, the stigma surrounding mental health care might prevent patients from seeking follow-up care, or following through on referrals. Secondly, the integrated system allows CHC to collect better data. Like water flowing through a pipe system, less distance traveled means less chance for leaks. The same principle applies to patient care.

Much of this data is then mined by the Weitzman Institute, located just a few doors down on Main Street in Middletown. Under the direction of Anderson, the Weitzman Institute identifies and tries to correct areas where the system is not working. One example is specialist referrals. “The whole system comes to a screeching halt if we need to send the patient to a specialist,” says Anderson, referencing the classic pitfall of many primary care providers in the community sector. Specialists like cardiologists often do not take Medicaid reimbursement, and wait times can be months long if they do. Anderson narrates the primary care provider’s internal monologue: “Gosh, I’ve done all this great work [with the patient], but I need the specialist to tell me what they think of this abnormal EKG, and I can’t get anyone to see [the patient].”

In the trial, seven out of 10 e-consults were resolved without a face-to-face meeting with the cardiologist. 

The results of the e-consult trial were published in the March/April 2016 issue of Annals of Family Medicine, and showed that electronic consultations “improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes.” After the research trial concluded, the Weitzman Institute showed the results to the state’s Medicaid department, which then authorized reimbursements to doctors who perform e-consults. Since the trial, CHC has expanded the e-consult program beyond cardiology into 10 different specialties.

The Weitzman Institute — which is named for Gerry Weitzman, longtime pharmacist at Pelton’s in Middletown who tragically died in a car accident in 1999 — is now researching the effects of different models of pain management to try to meet the growing problem of opioid addiction.

That the research arm of CHC is named for a beloved Middletown icon speaks to another defining characteristic of the organization. Though it has expanded into 14 cities across the state, CHC has always been very much a product of the North End of Middletown. CHC Senior VP and Clinical Director Margaret Flinter, a family nurse practitioner, quotes the late Barbara Starfield, a pediatrician and primary care innovator, in her description of the organization’s purpose. Primary care should be “close to where people live, work, play and pray. And you do it in a way that is affordable to the society as well as the people, and you take care of all but the most unusual conditions,” Flinter says. For play, there is Vinny’s Jump and Jive on Main Street in Middletown, open seven days a week, owned and operated by the health center. “We’re a little less white coat, and a little more about dance shoes,” Masselli says.

According to data furnished by Anderson, CHC’s health outcomes in at least two measures are better than the national data that exists for primary care. Using the Healthcare Effectiveness Data and Information Set, which is maintained by the National Committee for Quality Assurance, for comparison, CHC’s patients do much better. Anderson points to two comparisons: hypertension and diabetes control. “In 2015, between 53 percent and 61 percent of patients with hypertension and commercial insurance had well-controlled blood pressure. CHC’s rate is 64 percent,” he writes in an email. “In 2015, between 56 percent and 66 percent of patients with diabetes had good control. CHC’s rate is 76 percent good control.”

This feeling of control is evident in Jose Torres’ smile as we sit in the waiting room of the Bristol branch of CHC, as he waits to see the chiropractor. It’s evident in the smiles of his mother and girlfriend who both sit with him as he tells his story. Asked if there’s any part of his medical history that he wouldn’t want to see in print, he shakes his head no. “I’m very happy with what’s been going on with me here, and this is the best way to express it,” he says.