Paul Di Capua MED ’09 SOM ’09 unloaded his medical gear from the trunk of a Toyota. It was a typical day on the job for the primary care physician. Di Capua slung his bag onto his back, hiked a scale under his arm and then trooped across his patient’s lawn.

An elderly man with diabetes, hepatitis C and a heart condition waited for Di Capua. The man lived on the top floor of an apartment complex, and the steps leading up to his unit were narrow enough for Di Capua, a healthy middle-aged man, to have to climb slowly in order to not lose his footing.

An ashtray sat on the staircase. The smell of cigarette smoke greeted Di Capua as he entered the small apartment. After a warm welcome, Di Capua unloaded his gear and began a series of medical assessments, including taking the patient’s blood pressure and listening to his breathing. All the while, Di Capua conversed with the patient, making small talk and asking about his medications.

Afterwards, Di Capua turned the conversation.

“Can I look in your fridge?”

The refrigerator, adorned with both Meals-On-Wheels and CareMore magnets, contained little food. The patient explained that his next allowance of food stamps had yet to arrive, but that he still received a hot meal from Meals-On-Wheels every day for lunch. Di Capua, concerned about the patient’s blood sugar, asked about the sodas in the fridge and the sugary cereals on the counter, but the patient swore that his partner, not him, consumed them. Satisfied with his answer, Di Capua closed the fridge and reminded the patient to call the number on the CareMore magnet if he experienced any acute changes with his health.

Like any other primary care provider, Di Capua serves on the frontlines of health care. He is the first doctor that patients turn to when new symptoms of an illness crop up, and he helps his patients manage their existing health conditions. But unlike typical primary care practitioners, Di Capua and his team at CareMore — an East Haven-based center that serves New Haven county — treat only those with the highest medical need.

The typical CareMore patient in Connecticut lives alone and has a complex health profile, often including multiple chronic diseases, mental illness and difficulty with daily activities such as eating, bathing or toileting. Care for patients with this profile, according to Di Capua, amounts to over 75 percent of health care costs in the U.S.

“We are designed to deliver value, for concentrating a lot of resources on the most complex patients,” Di Capua said.

Systemic issues impacting physician reimbursement forces most primary care doctors to spend only a few minutes consulting their patients at each visit, according to Di Capua. For those with complex health profiles, like CareMore’s patients, that time is simply not adequate to fully address all of their health conditions. Many CareMore patients also face socioeconomic obstacles — such as food insecurity or unsafe housing and transportation — that might fly under the radar at other practices.

“Fifteen, 20 minute visits for patients who have unstable electricity,” said Jay Mathur, a CareMore physician. “I can do everything I want in terms of changing insulin — the amount of units you’re taking a day — but if you don’t have a refrigerator to refrigerate them in, does it really matter?”

CareMore turns primary care on its head. The center serves over 2,000 high-need patients between its East Haven and Hartford locations. Other CareMore centers are scattered across the United States and provide care to over 150,000 patients nationwide. Their Connecticut providers, which include physicians and nurse practitioners, visit patients almost exclusively in their homes. CareMore’s payment model allows their care team to spend a half an hour or more consulting with each patient.

“We’re pulling up a blank slate and saying, ‘Given the problems that these patients have, how do we create a health delivery system specifically tailored to their needs and to their problems and to their issues,’” Di Capua said. “To that end, we started by saying access is a huge issue.”

CareMore’s multidisciplinary team includes not just doctors and nurse practitioners, but also case managers, clinical social workers, community health workers and behavioral health specialists. They all work together to ensure that both health conditions and unsafe home environments seen on home visits are addressed.

For the patient Di Capua saw today, a CareMore social worker helped him find affordable housing in a first floor apartment. He will no longer have to climb the narrow steps at his current building, which pose a large fall risk for the elderly man.

CareMore’s case managers are also responsible for fielding calls from patients when acute health conditions develop. Patients will often call 911 out of fear and anxiety when these situations arise. Going to the hospital is not only expensive, but also puts patients — especially the elderly — at risk for infections acquired during their visit.

When CareMore’s case managers receive a call regarding an acute condition from a patient, they are trained to know right away if a patient needs urgent medical transport. The vast majority of cases, however, are often not life threatening and can be treated over the phone, saving the patient and the health care system undue strain.

“It’s much like a spider web or a neural [network] where you have different nodes in that net contributing to supporting the patient,” Di Capua said.

But it’s not just the patients that benefit. In a field where over 50 percent of doctors experience burnout, according to a MedScape survey, CareMore’s primary care providers say that they are far happier practicing at CareMore than they would be at other practices with constraints on time and resources.

For Mathur, it boils down to the additional time for consults.

“It comes back to having time to have these conversations with patients,” Mathur said. “It’s time. It’s sitting there, [allowing] five minutes [to] elapse. Hearing someone answer that question, ‘What do you like to do and how does health care get in the way of it?’ In a conventional setting, how do you have time to do that? You don’t.”

Di Capua emphasized the value of home visits. He said that CareMore’s model allows its doctors to provide a higher standard of care to their patients.

“When we enter into their homes we’re guests in their lives,” Di Capua said. “It’s one thing to see someone in the clinic and we’re on our home turf and they sit in our chair and are uncomfortable and wait for us to show up. Here I am — I walk into this person’s house and now I am their guest. I’m on their terms and more eyes-open to the reality that they live.”

Marisa Peryer  | marisa.peryer@yale.edu .