Inflammatory Bowel Disease (IBD) Patient-Centered Medical Home Delivers Integrated Multidisciplinary Care to Patients

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

So welcome, everyone, to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. I'm very pleased today to have one of my fellow colleagues, Dr. Miguel Regueiro who is the Pierre C. and Renee Family Endowed Chair in Gastroenterology and Hepatology. He's a Professor of Medicine and the Chair of the Department of Gastroenterology, Hepatology, and Nutrition. He's also the Vice Chair of DDSI, our Digestive Disease and Surgical Institute. Miguel, welcome to Butts & Guts.

Miguel Regueiro: Great. Thank you for having me, Scott.

Scott Steele: So very excited to have you on here. We always like to start out each of these podcasts with you telling us a little bit about yourself. Where are you from? Where did you train? How did it come to the point that you're here at the Cleveland Clinic?

Miguel Regueiro: Sure. So thank you for that, Scott. So I came to Cleveland Clinic in May of 2018. I originally was in Pittsburgh for the past 25 years at the University of Pittsburgh Medical Center. Grew up in Philadelphia, did all my training in Boston. I came here because I saw an opportunity in inflammatory bowel disease between medical surgical interface but also the population health initiatives and interest that I have in what's known as a specialty medical home.

Scott Steele: Yeah, that's absolutely something we're going to get into today. We're very excited to have you here at the Clinic. We've had ... For all of our listeners out there, we've had other talks about IBD, ulcerative colitis, and Crohn's disease, but for those that have not listened to them, give us the kind the 50000-foot overview on inflammatory bowel disease.

Miguel Regueiro: Inflammatory bowel disease afflicts about two million Americans. It's actually increasing in its prevalence so we're seeing more and more every year. We think it's environmentally triggered, but in simplistic terms, the immune system starts to attack the gastrointestinal tract. Crohn's, it can be anywhere in the gastrointestinal track from the mouth all the way down to the end in the rectum and the anus. Ulcerative colitis is in the colon. These patients often have problems with bleeding, diarrhea, pain. It can really change their lives. This is actually disease that we see in younger people. Unlike many that we see in this country where it's older, these are people between 10 and 40 years of age. So the prime of their lives in school and in work, getting started with their families, we often see these patients afflicted early.

Scott Steele: Crohn's and ulcerative colitis. I'm a surgeon. I take care of them. You're a medicine GI doc. You take care of them. What is this integrated role for the combined care for IBD patients?

Miguel Regueiro: One of the things I like about Cleveland Clinic and coming here and working with you and you and I have a shared clinic and I think we see this every day in our clinics with our patients. These patients often have inflammation that may respond to medication, but when the disease is too far gone meaning scarring in Crohn's disease or an ulcerative colitis where these deep ulcers aren't healing, we need, the medical side needs surgeons like you to take care of them. The flip side is we work in concert together because medicines are an important part of their care. Diet's an important part of their care. I really think this is a team approach to take care of these patients.

Scott Steele: So one of the things you want to delve right into is something that has really kind of been in your wheelhouse and that's this concept of the IBD patient-centered home. Can you tell us a little bit about that and kind of walk us through where'd you come up with this idea, where did it originate from, and how did you get to the point where you wanted to translate that into the care of the IBD patient?

Miguel Regueiro: The medical home isn't a physical building. Sometimes patients will ask "Where is this medical home built?" That's a common misconception. Really this derived out of primary care medical homes 10 years ago where we look at how can we take care of the whole person better in this what we call value-based proposition, so caring about the patient's quality of life, how they feel, but also looking at cost. So this home concept really simply put is for IBD the principle providers often us, the gastroenterologist and maybe not as much the primary care only because the patients otherwise don't have any other diseases.

The second part is it's really this interdisciplinary team concept, so medicine, surgery, but also importantly things like diet, stress, how psychosocial factors play a role. This can be a very stressful time and especially with this disease. So in essence, it's team-based care of the whole person. So we take care of the whole person. Now what we're doing is trying to implement digital technology. How can we keep people at home or in school and in work without having them come into the office repeatedly?

Scott Steele: What's the ultimate goal of the IBD home?

Miguel Regueiro: The ultimate goal would be actually to provide the best care possible, keep people at home and in work and in school, productive with their families, their friends, not having to come back and forth to the doctor, but also we're very cost-conscious. So you asked how did this all get started. So this started about six years ago when I was working with an insurance plan, a health plan. We looked at how can we better deliver quality care but at a lower cost. So cost has to be part of it, but the other part of it is how can we center the world, the medical universe around the patient. That is really the absolute driving force of a medical home.

Scott Steele: So you mentioned a little bit about who is the team, but walk me through the team members and maybe what role each of those team members play.

Miguel Regueiro: The team members can be several. I already talked about medicine and surgery so you and me, for example, in this concept, but important team members also include nurse practitioners, nurses, dietitians, psychologists, social workers. So what are their roles individually? The nurses essentially as I call it serve as air traffic control. So they become almost the coach, the direct contact that the patient has, the lifeline to the outside. When patients run into problem, they help navigate not only the whole medical system but what they may need on a daily basis: a new prescription or referral to a physician, vaccinations, something as simple as that. The nurse practitioners really become our extenders but also the primary providers of some of these patients. Sometimes I find in these models our nurse practitioners bond with the patients in a way where they really get to know them. They get to know their families. They help with the education. They help with the health maintenance.

The dietitians, I think that's probably self-evident, but the important part of that is we know that diet plays a role in inflammatory bowel disease. Probably the number one question our patients ask and for all of you out there is "What do I eat? How do I eat? What about my health?" So dietitians are fundamental. Finally, this concept of stress and the psychosocial part of a chronic disease and this is something we've seen time and time again and probably one of the biggest impact are the social workers, the psychologists, our health team that actually deals with behavioral health and stress. So these are some of the core fundamental concepts and the people. There are many more, but in essence, that's the core of the team.

Scott Steele: So you can open up any textbook and you can talk about how inflammatory bowel disease itself is kind of on a spectrum and some people have very severe disease and others really don't take any medications at all. So this IBD home, does everybody need it? Is there somewhere on that spectrum where you would start to think "I got to shift this person to IBD home? Of if I'm sitting at home and I'm like "I’ve got Crohn's disease, but it's not that bad. Do I got to call up my doctor and find out what this IBD home is?"

Miguel Regueiro: That's an excellent question. So the medical home initially was really built for all patients, and we still take all comers. It's not exclusive. However, I think you're making a very good point and we talk about this for the regional physicians that we work with, so the primary care physicians, the community gastroenterologists. Probably for about 50% of our patients as you indicated, mild, maybe they need to see the gastroenterologist or just their primary care doctor once a year to get a checkup or to get a prescription refill on a mild anti-inflammatory medication, but they're otherwise doing fine.

Probably those are the patients that don't need to come in to the home, but it's more the complex patients, either biologically meaning their inflammation's getting severe, maybe they need surgery, maybe they need a medicine, but also those patients who are really struggling with diet, with stress, they're in and out of the hospital, in and out of the emergency room. Those are the patients we funnel into the medical home.

Scott Steele: So when you look at this, you mentioned very briefly this started a little bit out of the primary care world and then working with insurance companies. So there must be some financial benefit to it, but what other type of benefits do medical homes offer overall to a system or to the patients themselves?

Miguel Regueiro: I think it's really all about quality and improving the patient experience. I know the motto here at Cleveland Clinic is "patient first" or "patient-centered." That's really the core essence of this. How do we better treat the patient? So one of the things when we were developing the medical home is what we realized is we have to ask our patients "What do you want out of the visit? What are your top three problems?" It's amazing to learn that sometimes us as gastroenterologists who are looking at these complex, different medications and we're getting prepared to talk about the patient, what medicines to use, patient's telling us "I can't afford my medicines. I'm a single parent with kids and I can't afford even to get in on the bus." I mean so we're really trying to take into account the entire aspect, the entire world of these patients. I think that's what the medical home provides the patients, and to the system, it's better quality and possibly we're going to reduce costs by not having our patients come in and out of the emergency room and the hospital.

Scott Steele: Are there any downsides to a medical home?

Miguel Regueiro: So I think the downsides are it's a new concept. Anything new is challenging. We know that. It's not been adopted in a wide spread way. I do see this now happening in other chronic diseases, so in rheumatology, neurology. Certainly oncology has done this for a long time, but it's hard because it's building a concept that we're not used to. We're used to a different concept and construct. This is a team-based concept where we're working with payers, we're working with technology. I think it's exciting. I think medical schools are now training the graduates of tomorrow toward these programs, but traditionally, this has not been something that's been done for years.

Scott Steele: So could you clarify a little bit about the current status of the medical home here at the Cleveland Clinic?

Miguel Regueiro: The medical home is up and running. Even though we started in May, we've hired most of the positions. We actually have all the positions approved so the team is coming together. Scott, you and I work closely in essentially a medical home concept already with our patients. We see our patients every day. I think what we're now looking towards and what I'm very excited at the Cleveland Clinic is this idea of specialty population health. So we're looking at this medical neighborhood now through our electronic system, and we can link to primary care physicians in the region and gastroenterologists to do these consults virtually and then define, maybe like you said, what patient should just stay in their community and maybe what patient should come into this home.

Scott Steele: Where do you see the future for these IBD medical homes? One of the things you had talked about very briefly was the IBD neighborhood. Talk a little bit about that and then where you see this going.

Miguel Regueiro: I see this going to, again, a larger population health initiative. So the medical home is really centered right now around a hospital and a system, but as we get better with our technology and linking people together, I see this actually evolving into something where, for example northeast Ohio, we're reaching out to an entire community around inflammatory bowel disease and linking in a way we haven't done before and possibly now even nationally. Where this really will come up is as we start new contracts with insurance plans and health plans and we look at these models of care. This is going to be something certainly we're going to pioneer here. I think we'll probably we a leader at Cleveland Clinic, but certainly there are other systems looking at this as well.

Scott Steele: What things have you learned along the way, bumps in the road that you feel like you kind of got to take it over and go from there?

Miguel Regueiro: Yeah. I've learned to be very humble and that failure is usually the result of many tries, but then success comes over time. I think what it is really continuing to listen to the patient. I mean that's really what's the central part of this. So whenever we're stuck or trying to figure out what to do, involve our patients as stakeholders, ask them what they think about certain ideas. That's really what I've learned more than anything, is we need the patients to be involved in this to show us and teach us as physicians how we better build these models.

Scott Steele: So if I'm a patient at home listening to this podcast and I hear this, what are the next steps for the patient? I mean this is exciting to me and I'm like "I want to be a part of that." What do they do? What are the next steps for them?

Miguel Regueiro: So I think the next steps for them and depending on where they are listening to this is certainly in the region that they work with. Ask their gastroenterologist, ask their primary care physician, are there these new models in their region? Certainly in northeast Ohio if there's an interest, we're happy to get them in. We're happy to work with their primary care physicians. We're happy to work with their gastroenterologist. We're looking to help as many people as possible, but we also don't want to make this a detractor for what their daily lives are. So we're really here to help.

Scott Steele: So in addition to the IBD home, we talked a little bit about the future, that as one of world-renowned IBD-ologists, gastroenterologists. What are some of the new things on the horizon for IBD care for patients?

Miguel Regueiro: There's quite a bit of research now going on in the microbiome. So that's the bacteria in our guts and how the gut bacteria actually lead to probably inflammation and importantly how the environment and diet play a role in that as well. Cleveland Clinic is really a pioneer looking at diet, functional medicine, different outcomes in terms of the microbiome. Then there's a whole host of novel treatments that are coming out that fortunately we've been involved in many of those trials here and that we know about them nationally, but probably new therapies that we've never seen before. Then finally, how do we integrate with you all, the surgeons, and come up with better care plans? Because we still need surgery as part of this, but we have to figure out not only technically but then medically how to treat these patients around the time of surgery.

Scott Steele: That's extremely exciting stuff. So we always like to end up all of our guests with some quick hitter. So favorite food?

Miguel Regueiro: Favorite food, that's a hard one. Steak.

Scott Steele: All right. Favorite sport?

Miguel Regueiro: Favorite sport, soccer.

Scott Steele: What is the last nonmedical kind of fun book that you read?

Miguel Regueiro: So actually I'm reading Game of Thrones because I got into the show and I went back and decided to read the book.

Scott Steele: Then you mentioned that you spent most of your time on the east coast and in Philly and obviously coming from Pittsburgh, we won't mention the Steelers, but tell us something that you like about Cleveland.

Miguel Regueiro: The people are great. It's a culture and a very friendly community. Everybody's very warm and welcoming. I can't say that I like the football here yet, but maybe that will change over time.

Scott Steele: It for sure will. So for more information, please visit clevelandclinic.org/IBD. That's clevelandclinic.org/IBD. To schedule an appointment with a Cleveland Clinic specialist, please call 216.444.7000. That's 216.444.7000. Miguel, thanks for joining us on Butts & Guts.

Miguel Regueiro: Thank you very much, Scott.

Scott Steele: That wraps things us here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.