A local doctors office has become a key component of an ambitious, team-based project that could change the face of the entire health care system.

For the past year and a half, Lone Tree Family Practice has diligently monitored patient health by utilizing its staff to track numbers, adjust treatment methods and even make calls to those who might need a check-up.

The office, led by primary physicians and practice owners Christine Linares, M.D. and Chester M. Cedars, M.D., became a certified Patient-Centered Medical Home and one of 17 family practices in the state to participate in a study to determine the potential benefits and drawbacks of a team-based approach to wellness.

The practice applied for the voluntary program, met a set of strict criteria outlined by the National Committee for Quality Assurance, and is now working with Health TeamWorks, an organization that provides a facilitator who monitors the progress of each practice and reports the results to high-level decision-makers.

The organization is partially funded by federal grants, but the study is being paid for by some of the top health insurance companies in the country. The results might lead to overhauls that could eventually lower skyrocketing healthcare costs, especially as the baby boomer generation ages.

“We can’t continue to do this kind of shooting out into space thing with the cost of health care,” Linares said. “We’re going to have to rein it in somehow and I think there are a lot of us that feel something like this can help rein in that cost.”

The staff at Lone Tree Family Practice is not expected to carry the entire burden of responsibility. Patients become more informed about their conditions and are expected to join the team by helping to monitor symptoms and taking preventive measures to better their health. Patients eventually become more engaged and take on more responsibility.

“The team is not just the physicians and the nurse practitioners, but it’s also the rest of the staff, and the patient is a member of the team, because for certain diagnoses, the patient is responsible to help maintain their health,” Cedars said.

Patients do not always divulge their entire medical history, and the sharing of information is a critical piece of the team puzzle. However, there are some specialists who resist giving out patient information, even to their primary care doctor.

The Patient-Centered Medical Home crew in Lone Tree tracks the progress of all patients, especially those with chronic diagnoses, such as diabetes, hypertension and high cholesterol. Team members monitor lab values, vital signs and side effects, and the patients who are not adequately controlled are contacted by phone or e-mail. It is a proactive tool that reminds infrequent visitors to get an evaluation.

The practice has seen more than 4,000 patients within last two years, and tracking that number of people required additional people. More staff members were brought on because it would be impossible for two doctors to monitor the health of every patient, Cedars said. Data sheets and graphs that track the progress of all patients in specific categories, including diabetics, are reviewed monthly and sent on to the insurance companies. The 17 Colorado practices involved in the study also use conference calls to discuss the challenges and improvements they see. The national pilot project is scheduled to wrap up in less than six months, but could be extended by one year to allow more time for research.

Lone Tree Family Practice, located in the Aspen Building at Sky Ridge Medical Center, is already attempting to reshape the typical doctor visit through communication and comprehensive education. Linares said their goal is to phase out the quick, 10-minute question-and-answer session that usually ends with the physician writing a prescription and requesting a return visit.

“There’s no discussion about why and what’s this medicine going to do to me and what are the side-effects,” she said.

The team also leads group visits in which 10-15 patients with the same condition gather to discuss treatments, symptoms and learn about the illness from a doctor or physician’s assistant.

“People start to buy-in” when they gain more understanding about their condition, Linares said.

Health TeamWorks put together an aggressive set of goals for patient improvement, and progress is tracked by concrete numbers and patient satisfaction surveys. The information is reviewed by the insurance companies, health professionals and even federal authorities.

“There is a lot of talk about how to shift medicine in the direction of preventive care on a national level, and our hope is that we’re going to be on the front end of that,” Linares said. “We’ve done a lot of quality improvement already. We plan on continuing that as part of the culture of the office.”

Many of the patients at Lone Tree Family Practice, the headquarters of the Patient-Centered Medical Home in Lone Tree, are unaware that the office is participating in the program, which has not yet received a significant amount of national press.

Cedars said his goal is to eventually convince the insurance companies, through proven models, of the effectiveness of team-based preventive health care so they will continue to fund the additional staff needed to keep the program going strong. If the funding disappears, the practice will continue trying to improve the health of its patients.