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.

Related links:

• Curing Healthcare: Deploying a Patient-Centered Medical Home ...
• Curing Healthcare: Patient-Centered Medical Home and Health IT
• Curing Healthcare: Four Interlocking Issues about Fixing American Healthcare

Case for a Collaborative Health-Support Software System - Part 2 of 3

In my previous post, I presented a case for using collaborative health-support software systems in loosely-coupled networks of healthcare professionals and consumers. This post focuses on how to implement such systems and networks in a way that increases value to the consumer.

How Using Health-Support Software in Loosely-Coupled Networks Promotes High-Value Care

When people use health-support software in loosely-coupled networks, they increase care value by:

• Fostering coordinated care
• Delivering consumer-centered cognitive support
• Sharing decision-making.

Fostering Coordinated Care

Coordinated care is a strategy for ensuring that consumers being treated by multiple providers in loosely-coupled networks—including primary care physicians, biomedical and mental health specialists, and wellness coaches—who work together in a synchronized manner to deliver high-value services. Methods for implementing this strategy include the use of personalized health-support software to deliver whole-person integrated care and support medical home deployment.

Using Personalized Health-Support Software

Healthcare providers delivering coordinated care in loosely-coupled networks require different types of health-support software. That's because providers in the network typically work at different locations, use disparate information systems, and are from different healthcare disciplines that require different health information. For example, a primary care physician, being a generalist, needs a broad spectrum of patient information covering patients' biomedical, psychological, and environmental factors (including data about current medical conditions, medications being taken, allergies, vital signs, basic lab results, medical history, stress and other emotional factors, etc.). While all providers would benefit from similar information, a specialist would benefit from a more in-depth sub-set of data related to their area of specialization.

A cardiologist, for example, would benefit from data related to heart functioning.[1] A dentist would benefit from data about previous dental work done, dental x-rays, existing medical conditions affecting teeth and gums, etc. A mental health practitioner would benefit from detailed information about the relationship between a person's thoughts, emotions, and behavior, as well as psychosocial data, etc. A holistic (integrative/integrated medicine) practitioner would benefit from addition information about the mind-body connection, metabolic functioning, etc. Furthermore, the consumer would benefit from a personal health profile report that includes risk-appraisal, current health status, and self-management information in lay language. That means successfully coordinating care requires use of many different health-support software in loosely-coupled networks.

In other words, health-support software should be personalized, that is, tailored to each person's particular requirements.

Delivering Whole-Person Integrated Care

Delivering whole-person integrated care has two components:[2]

1. The whole-person part focuses on improving a person's health and wellbeing by addressing one's physical health (body), mental/psychological health (mind), and the mind-body connection ("holistic" health). In other words, it views an individual as a whole entity, whose body and mind are interconnected.
2. The integration part refers to integrating well-care with sick-care. Instead of viewing sick-care (treatment of illness and dysfunction) and well-care (preventions and self-management of chronic conditions) as two separate avenues in the road to health, sick-care/well-care integration refers to an integrated care delivery system.
   Instead of viewing sick-care and well-care as two separate avenues in the road to health, this integrated approach involves a new kind of coordination and collaboration between (a) medical and related sick-care practitioners focused on the diagnosis and treatment of health problems and (b) well-care practitioners focused on prevention, recovery and well-being, as well as peak performance.[3]
   

An example of the whole-person integrated care approach is when people with chronic illnesses receive care from their medical providers, along with coaching, instruction and social support from a health education and support program. While the people's doctors deal with medical issues (including medical procedures and medication subscriptions), the health program focuses on enabling and motivating the individual to self-manage chronic conditions (such as diabetes) by developing healthy attitudes and beliefs, emotions, coping strategies, psychosocial relationships, and life satisfaction, as well as gaining essential awareness, knowledge and skills.[4]

Since this type of whole-person integrated care involves multidisciplinary teams of providers, as well as the consumer's social connections, the individuals involved form a loosely-coupled network. The health-support software they use, therefore, should focus on:

• Giving the providers timely information about consumers' progress and blocks
• Enabling the professionals to collaborate easily and efficiently
• Sparking helpful conversations among the social networks
• Educating and instructing the consumers, as well as providing ongoing health status feedback.

Deploying Medical Homes

Instead of a fragmented healthcare delivery system as exists today, continuity of care through medical home makes a person's primary care physician responsible for coordinating the services rendered by the multidisciplinary team of providers working with the person.[5][6] Health-support software for medical homes[7] focus on enabling the providers to know what each other is doing, their care the deliver is better connected, which helps improve quality and reduce costs by avoiding duplication of tests, medication conflicts (e.g., due to drug-drug interactions[8]), inappropriate or conflicting procedures, etc.

Delivering Consumer-Centered Cognitive Support

Consumer-centered cognitive support assists healthcare providers and consumers in finding useful answers, making valid health decisions, collaborating effectively, and taking competent, responsible action. This support increases care value through use of collaborative health-support software that:

• Analyze and help interpret voluminous, complex diagnostic, treatment, and outcomes data
• Identify existing and threatening physical and mental health problems
• Search for scientifically validated options (diagnostic, treatment and preventive)
• Help develop high-value (effective and efficient) plans of care
• Enable loosely-coupled networks of providers, consumers and researchers to share and discuss lessons learned (e.g., observations, insights, hypotheses, explanations, and anecdotal information)
• Continually evolve clinical knowledge by providing ongoing process and outcomes data to researchers for evaluating, building and modifying evidence-based guidelines.[9]

Promoting Provider Competence

Collaborative health-support software can promote provider competence by delivering consumer-centered cognitive support information. That is, provider's diagnostic and treatment decisions, and the implementation of those decisions, can be supported and improved through by the software's data analyses, care-plan assistance, and evidence-based guidelines.

Promoting Consumer Competence

In addition to assisting healthcare providers, consumer-centered cognitive support helps consumers acquire the knowledge, skills, and characteristics needed to make wise decisions and act in ways that improve one's health and wellbeing.

For health-support software to promote consumer competence, it should collect and analyze comprehensive, valid, reliable (complete, accurate, and dependable) data. These data are facts and figures, collected on multiple occasions (over time), which include:

• Internal biological measures (biometrics) such as height, weight, blood pressure and other vital signs, cholesterol level, blood glucose and other blood component levels, imaging studies and lab tests, illnesses, allergies, genetics, etc.
• Psychological measures of mood and emotions, cognitions (thoughts and beliefs), behaviors (e.g., exercise, eating, sleeping, smoking, substance and alcohol use), social relationships, learning styles and (dis)abilities, significant past experiences (e.g., memories, traumas), etc.
• Healthcare treatments, including medications taken, procedures received, and their outcomes
• Preventive actions, such as inoculations, wellness coaching, and health education
• Demographics, which include age, gender, finances, ethnicity, etc.
• Environmental conditions, past and present, including neighborhood crime levels, pollution, etc.

All these data must be analyzed using valid computational methods that generate actionable information that helps consumers make valid predictions, build useful knowledge and skills, make sound decisions, increase positive motivation, improve physical health, and have greater peace of mind (e.g., reducing mental stress and emotional distress). This information should include:

• Trends and tendencies, which give insights into what is likely to happen in the future by studying what has been happening in the past and in the present
• Associations (relationships, interactions) showing the connection between body, mind and behavior
• Warnings and alerts indicating, for example, when it's time for a medical check-up or inoculation, when there are possible drug-drug interactions a person is having serious medication side-effects, if one's lab tests indicate a health problem, etc.
• Guidelines and instructions informing a consumer about how to deal with a risk factor or health.[10]

Sharing Decision-Making

Shared decision-making occurs when healthcare consumers are able to make knowledgeable decisions about their own care in collaboration with their providers. It reflects the principle of self-determination and involves respecting people's right to define their own view of what is good for them and to pursue that view, as well as to give others the authority to make particular health care decisions for them. To make shared decision-making successful, healthcare providers must not only to understand consumers' needs and develop reasonable ways to meet those needs, but they must also present the alternatives in a way that enables consumers to make a knowledgeable choice. They must also take into account consumers' attitudes, preferences, and values.[11]

The Center for Shared Decision Making[12] employs decision-making coaches who use various decision-making aids, including pamphlets and videos, to help consumers examine and weigh their options about tests and treatments. Collaborative health-support software can be useful in shared decision-making by offering similar, computer-generated information to loosely coupled networks of coaches and consumers.

To summarize: High-value care—both provider-supplied and self-care—relies, in part, on the use of continually evolving, personalized, health-support software in loosely-coupled collaboratives to:

• Foster coordinated care
• Deliver consumer-centered cognitive support that promotes competent both professionally-rendered care and self-care
• Enable shared decision-making.

In my next post, I'll introduce and describe the first collaborative health-support software system.

References and Notes:
[1] Data useful to a cardiologist includes the location of chest pain, ST elevation or depression, Q waves or left bundle branch block, T wave inversion or hyperacusis, CKMB and Troponin T or I levels, and heart imaging studies, etc.
[2] http://curinghealthcare.blogspot.com/2008/02/patient-centered-life-cycle-value-chain.html
[3] http://wellness.wikispaces.com/Tactic+-+Well-Care+Sick-Care+Integration
[4] http://curinghealthcare.blogspot.com/2008/12/whole-person-approach-to-diabetes.html
[5] http://coordinatedhealthcare.com/index.php/hcnews/1-medicalhome.html
[6] http://wellness.wikispaces.com/Tactic+-+Implement+the+Advanced+Medical+Home+Model
[7] http://www.nhds.com/ccrplus.html
[8] http://www.fda.gov/cder/consumerinfo/druginteractions.htm
[9] http://curinghealthcare.blogspot.com/2009/01/consumer-centered-cognitive-support.html
[10] http://curinghealthcare.blogspot.com/2009/02/competent-healthcare-consumer.html
[11] http://bioethics.gov/reports/past_commissions/making_health_care_decisions.pdf
[12] http://www.dhmc.org/shared_decision_making.cfm