Friday, May 15, 2009

Patient-Centered Medical Home: Gaining Traction

I want to commend the National Committee for Quality Assurance (NCQA), the American Academy of Family Physicians (AAFP), and other physician-based organizations involved in writing the Standards and Guidelines for Physician Practice Connections®—Patient-Centered Medical Home (PPC-PCMH™), which is available at this link.

I first wrote about the medical home concept in 2006 as being a key component for our healthcare crisis at this link. I followed it up in 2007 with a blog post at this link and then again in 2008 at this link.

The joint principles of the PCC-PCMH are:
Personal physician—Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice—The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation—The personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services and end of life care.
Care is coordinated or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.
Quality and safety are hallmarks of the medical home.
  • Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients and the patient's family.
  • Evidence-based medicine and clinical decision-support tools guide decision making.
  • Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
  • Patients actively participate in decision making and feedback is sought to ensure patients' expectations are being met.
  • Information technology (IT) is utilized appropriately to support optimal patient care, performance measurement, patient education and enhanced communication.
  • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
  • Patients and families participate in quality improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. While aspiring to improve patient care, the four primary care groups envision implementation of the PCMH as linked to more rational (and higher) payment for primary care, which is in very fragile status in the U.S. The four primary care groups, aided by others, have held discussions with employers, health plans and the federal government to encourage the development of PCMH implementation/demonstration programs. In concert with the joint principles, the PPC-PCMH standards emphasize the use of systematic, patient-centered, coordinated care management processes.
These principles are both sound and doable! After seeing many good ideas evaporate due to lack of will and competing interests, I'm encouraged that strategies such as the patient-centered medical home are finally gaining real traction.

There are critics, however. For example, a recent article, titled Effectiveness of medical homes questioned, discussed how the “…effectiveness of medical homes as a tool for improving care was called into question at a hearing of the Senate Health, Education, Labor and Pensions Committee…[because of] ‘concerns about how to best design and implement such a model’…Some believe requiring physician referral for specialty services under a medical home model might introduce a costly and needless step to linking patients to the right source of care [arguing that] primary care is not always the most cost-efficient and effective provider for every condition and disease.”

I agree that critical evaluation of all healthcare delivery models (including the patient-centered medical home) is a good thing. But I do not agree with the criticism that primary care physicians (PCPs) may not be the best people to manage care coordination, even though certain PCPs will likely do a better job than others in coordinating care. As a group, however, PCPs, being generalists, seem to me to be the ones best suited for the job. Nevertheless, it’s important that our healthcare system enable PCPs to provide this crucial service by supplying them with effective health IT tools and paying them enough to spend the time necessary to coordinate and evaluate care being rendered to their patients. Over the long term, this will likely save money, especially when treating patients with chronic conditions, by eliminating duplication of tests and having multidisciplinary teams collaborating effectively.

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