The first thing patients probably notice when walking into the new doctors offices at Greater Baltimore Medical Center is there is no waiting room.
Patients go directly to an exam room, where doctors, nurses and other staff are supposed to cycle in during a half-hour appointment. All supplies are on hand, as are electronic medical records, to ensure that people leave with any needed prescriptions or referrals to specialists.
The design is patterned after one used by a Seattle medical system, which modeled it after Toyota's production system.
The so-called "patient-centered medical home" concept aims to improve work flow, improve patient care and cut costs. The GBMC office on the Towson hospital's campus is among several in Maryland that are becoming medical homes.
The movement was encouraged by the federal Affordable Care Act, which provided states with money beginning in 2010 to pay for electronic medical records and pilot programs that compensate doctors for healthier patients.
GBMC patient Susan Erlich, a 49-year-old Pikesville resident, said she feels like she's the "center of attention" at the new office, with nurses and doctors coming to her. Even registration is done in the exam room.
"My new doctor not only returns my calls but even scheduled me at the end of the day so I could have more than the allotted 30 minutes because I felt like I needed more time," she said. "I think the system will save money in the long run, but it's just better service."
Erlich said she believes her doctors are doing all they can to keep her out of the hospital by ensuring that she's got her medications for a chronic condition and can easily see a provider in the office, where care is cheaper than the emergency department. She said her previous doctor was quick to tell her to go to the emergency room and once didn't notify her for four days that she had pneumonia.
Each institution's approach can be different. In many cases, doctors offices began adding hours and last-minute appointments and implementing secure systems so communications between doctors and patients can be kept private. They also began a more concerted effort to coordinate patient care among all caregivers, including specialists and hospitals.
Making the model work requires the right infrastructure as well as buy-in from staff to improve care coordination and communication, said Dr. John B. Chessare, president and CEO of GBMC HealthCare System. The new GBMC offices opened in mid-October.
"You can set up in a garage and make it work if the medical team gets it," said Chessare. "The first step is making sure everyone is accountable for a patient's health. But giving them the space to do it is the next correct step."
The University of Maryland Medical System's UniversityCare in Edmondson Village was one of the first in the state to gain accreditation as a medical home by a national standard-setting group more than four years ago.
Earlier this year, the health care provider Chase Brexton moved a host of services under one roof at its Mount Vernon offices and redesigned space like GBMC to bring medical staff to the patient.
CareFirst BlueCross Blue Shield, the largest insurer in the state, launched a "patient-centered" program in 2011, offering doctors higher reimbursements for better patient outcomes. At the time the program began, company officials said that 5 percent of those the insurer covered, or about 3.5 million people, were making up to 40 percent of the claims, mainly by going to the hospital.
In July, CareFirst reported that 80 percent of its providers participate and the rate of spending for members has slowed from an average annual increase of 7.5 percent in the five years preceding the program to 3.5 percent in 2013. That translated into $267 million in avoided costs over three years.
Compared to those not in the program, CareFirst-insured patients logged 6.4 percent fewer hospital admissions, 11.1 fewer days in the hospital and 11.3 fewer outpatient health facility visits, the insurer reported.
CareFirst President and CEO Chet Burrell said in the report that the numbers "give us confidence that our program is taking hold and headed in the right direction."
But Burrell noted that health care spending nationally has trended downward. While he said he believes the program has contributed to the decline, "it would be unfair to attribute these shifts solely to our program."
The Patient-Centered Primary Care Collaborative, an advocacy group, points to anecdotal evidence of success by CareFirst and other insurers and health systems.
But the group said there are no uniform evaluation methods for patient-centered medical homes. Further, some patient-centered medical homes are not accredited, and the requirements vary among accrediting organizations.
A study of Medicare patients, published in July in Health Services Research, found bigger drops in emergency visits and more savings from patients who used a medical home accredited by the nonprofit National Committee for Quality Assurance, the largest group certifying medical homes, compared with nonaccredited medical homes.
Researchers concluded that the study "provides additional evidence about the potential of the [patient-centered medical home] model for reducing health care utilization and the cost of care."
Administrators at Virginia Mason Medical Center, on which GBMC's office is modeled, began looking for a new way to improve efficiency and quality in 2000. They had discovered, for example, that nurses in the main hospital were walking six miles to collect supplies every day and spending just 30 percent of their time with patients, who were at risk for falls and other harm when left unattended.
Once boxes of the most used supplies were placed in the rooms, nurses spent about 90 percent of their time with patients, said Chris Backous of Virginia Mason Institute, a nonprofit launched by the center for education and training.
The medical system has built new facilities that incorporate other "lean manufacturing principles" and retrofitted older buildings.
Dr. Ben Hand, a GBMC doctor who visited Seattle for ideas, said everything adopted here benefits patients. The standard half-hour appointments give doctors flexibility to ensure that patients who come in with a cold can also get a physical or a referral for a mammogram.
Even when patients aren't there, staff can still coordinate care. For example, the office gets a daily report from a new statewide electronic system that tells which patients have been hospitalized and uses it to schedule follow-up care.
Hand said there are still issues in coordinating patient care, such as getting timely discharge information from hospitals or feedback from specialists. And when four patients arrive at once, someone will have to wait. But he said the new office is working well.
"Many family medicine doctors have been clamoring for changes for years," Hand said. "We knew we had to make the economics work, but we felt we could save money in the long run and keep our patients healthier if we were more proactive upfront."