On a Monday afternoon in December the Moreau Family Health Center, just south of Glens Falls, is packed. Dr. Tucker Slingerland is seeing patients back-to-back, and so is care coordinator Jessica Casey.

Just as Jessica introduces herself, the phone rings. It's a patient. She helps him figure out his prescriptions. She schedules an eye surgery appointment and arranges the patient's transportation by coordinating with his sister.

Jessica's job – being a link between doctor, patient, and other services – is part of a new model of primary care in the Adirondacks still in the pilot stages. It's called a patient-centered medical home.

Warrensburg Health Center, one of the clinics participating in the medical home pilot project. Photo: Sarah Harris

The hope was to keep doctors in the Adirondacks, improve patient care, and reduce health care costs.

"The idea is to not just have the doctor and patient together, but a whole team of people caring soup to nuts doing the patient coordination, doing most of the care right there in that primary care setting."

Health centers across Warren, Hamilton, Essex, Clinton and Franklin counties decided to participate. Public and private insurers signed up, paying $7 per patient per month. And three years ago, the pilot was up and running.

Doctor Tucker Slingerland, the physician at Moreau Family Health Center, says it's changed his practice.

"Now before I go in the room there's a team nurse that's in there, so much of the encounter is happening before I even get in there," Slingerland says. "I try and help the patient make the complicated decisions. It's forced us to define we think quality is and what things we think make a difference for patients."

Sherman Hurlbert is one of Dr. Slingerland's patients. He has chronic diabetes, pancreatitis, and asthma. He's a retired nurse, and says the medical home program has helped keep him out of the hospital.

The 47 participating health centers have digitized medical records that can be accessed by providers across the region. It's not yet clear what impact the medical home pilot has had on costs for patients. But they're starting to see health results.

In the southern Adirondacks, diabetes patients had better controlled sugars, blood pressure, and cholesterol within a year of the pilot program.

 In the northern Adirondacks, hospital readmission rates for a select group of patients have been cut in half, and pediatric emergency room visits are down 18 percent.

And that has affected the business of hospitals.

Glens Falls Hospital, Adirondack Medical Center in Saranac Lake, and CVPH in Plattsburgh have all laid off employees this fall, in part because of lower patient volumes.

"Our cost structure is built on those pediatric ER visits coming in. and they're not there anymore," says Stephens Mundy, head of CVPH. "We have to figure out how to retool. We shouldn't have patients just coming to the hospital because we need them to come for financial reasons. That's a wrong answer. And we want those patients to get care in an outpatient setting and we have to adjust internally."

Advocates of the medical home say it's the way forward.

"For this part of the Adirondacks, the medical home is health reform," says Dr. John Rugge. "This is how we're tackling it. Physicia­­­ns, hospitals, communities have the opportunity to find solutions that work for them. We think this is the kind of approach we need here in the mountains."

Support for the Innovation Trail comes from the Corporation for Public Broadcasting. The Innovation Trail is a collaboration between six upstate public media outlets, reporting about New York's innovation economy. You can find more at innovationtrail.org.