Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Patient-Centered Care

In my previous posts, I've discussed the benefit of integrating the three macro processes of the PCLC Value Chain strategy: emergency-care, sick-care & well-care. In my next series of posts, I'm going to focus on our healthcare system's problematic clinical and financial processes. I'll be examining ways to reform these processes so they enable the PCLC Value Chain strategy to succeed in increasing increase healthcare effectiveness, efficiency and access. I begin with the transformation to "patient-centered" care.

Patient-Centered Care

To define patient-centered care, let's start by contrasting it with the kind of non-patient-centered care we have today. We currently have a fragmented healthcare system in which:

• Plans of care are typically one-size-fits-all, which means clinical guidelines are rarely tailored to a patient's particular needs an preferences
  
• The vast majority of practitioners use paper-based patient records or electronic records that are not interoperable, which means sharing patient data between providers is inefficient at best and non-existent at worst, resulting in poor coordination of care when multiple clinicians treat the same patient
  
• Collaboration between providers, and between providers and researchers, is weak, which hampers knowledge growth and exchange
  
• Patient education tends to be insufficient and compliance to plans of care is low
  
• Transparency of cost and quality is grossly inadequate
  
• Profit is tied to quantity, not to efficiency and effectiveness.

In contrast, the patient-centered healthcare model I'm proposing focuses on prevention, delivery of cost-effective treatments that take into account patient preferences and unique needs, care coordination, and enhanced self-management of chronic conditions.

The following six core elements are identified most frequently in the literature as essential for patient-centered care:

• Education and shared knowledge
  
• Involvement of family and friends
  
• Collaboration and team management
  
• Sensitivity to nonmedical and spiritual dimensions of care
  
• Respect for patient needs and preferences
  
• Free flow and accessibility of information
  

…Seven key factors contribute to achieving patient-centered care at the organizational level are:

• Leadership, at the level of the CEO and board of directors, sufficiently committed and engaged to unify and sustain the organization in a common mission.
  
• A strategic vision clearly and constantly communicated to every member of the organization.
  
• Involvement of patients and families at multiple levels, not only in the care process but as full participants in key committees throughout the organization.
  
• Care for the caregivers through a supportive work environment that engages employees in all aspects of process design and treats them with the same dignity and respect that they are expected to show patients and families.
  
• Systematic measurement and feedback to continuously monitor the impact of specific interventions and change strategies.
  
• Quality of the built environment that provides a supportive and nurturing physical space and design for patients, families, and employees alike.
  
• Supportive technology that engages patients and families directly in the process of care by facilitating information access and communication with their caregivers.
  

…Key strategies identified as necessary to overcome barriers and to help leverage widespread implementation of patient-centered care can be divided into the following two groups:

• Organization Level. Strategies designed primarily to strengthen the capacity to achieve patient-centered care at the organization level include:


• Leadership development and training
  
• Internal rewards and incentives
  
• Training in quality improvement
  
• Practical tools derived from an expanded evidence base
  


• System Level. Strategies aimed at changing external incentives in the health care system as a whole, to positively influence and reward organizations striving to achieve high levels of patient-centered care, include:


• Public education and patient engagement
  
• Public reporting of standardized patient-centered measures
  
• Accreditation and certification requirements.[1]
  

Patient-Centered Medical Home

One implementation of patient-centered healthcare is the "advanced medical home"[2]--also called a "patient-centered medical home"--which is:

...a model of care that puts the needs of the patient first. The medical home is the base from which health care services are coordinated to provide the most effective and efficient care to the patient. This includes the use of health information technology, the coordination of specialty and inpatient care, providing preventive services through health promotion, disease management and prevention, health maintenance, behavioral health services, patient education, and diagnosis and treatment of acute and chronic illnesses...Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. The medical home is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of patients...Quality and safety are the hallmarks of the medical home. Evidence based medicine, health information technology, and clinical decision support tools guide decision making to support patient care, performance measurement, patient education, and enhanced communication. Ensuring the coordination and comprehensive approach of the medical home model over time will improve the efficiency and effectiveness of the health care system and ultimately improve health outcomes.[3]

The above definition describes the kind of highly functional patient-centered medical home that is most closely aligned with the PCLC Value Chain and of greatest benefit to patients. Unfortunately, few exist today. But if we "water down" the definition to mean little more than a regular doctor or source of primary care who (a) has information about patients' medical history, (b) can be contacted by phone during office hours, and (c) coordinates care--then more exist, though not nearly enough. While the benefits to patients are not as great with this less functional type medical home, it can still help improve outcomes and value to the patient; consider the following:

Cross-national and U.S.-specific studies find an association between access to comprehensive primary care and both better health outcomes and lower medical costs. In light of such evidence, a movement has emerged to transform primary care practices into "medical homes" that provide an array of patient services in an efficient manner…[but] only about half of adults in all seven countries have medical homes. In each country, patients with medical homes reported more positive care experiences than those who did not, including more time spent with their doctors and greater involvement in care decisions.

In the U.S., the uninsured were at high risk of missing such a connection to the health system: just 26 percent of uninsured adults under age 65 had a medical home, versus 53 percent of the insured.

Those with a medical home were also much less likely to report medical errors, receive conflicting information from different doctors, or encounter coordination problems.

"Achieving better care coordination will likely require designs that include a mix of formally integrated organizations, co-locating or sharing services, and connecting through information systems," the authors conclude. "Developing medical home approaches offers the potential to move toward higher performance."[4]

The delivery of patient-centered care, including the extensive use highly functional medical homes, is therefore one systemic reform process that would bring value to the patient. In my next post, I discuss another: Value-Based Competition.

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[1] Shaller, D. (October 2007) Patient-Centered Care: What Does It Take?, The Commonwealth Fund, Volume 74. Available at http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=559715&#doc559715
[2] Available at http://wellness.wikispaces.com/Tactic+-+Implement+the+Advanced+Medical+Home+Model
[3] Available at http://www.patientcenteredprimarycare.org/medicalhome.htm
[4] C. Schoen, R. Osborn, M. M. Doty, M. Bishop, J. Peugh, and N. Murukutia, Toward Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007, Health Affairs Web Exclusive October 31, 2007 26(6):w717–w734. Available at http://www.cmwf.org/usr_doc/Gauthier_highperformance_909.pdf