Medical home

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The medical home,[1] also known as the patient-centered medical home (PCMH), is a team based health care delivery model led by a physician, P.A., or N.P. that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.[2][3] It is "an approach to providing comprehensive primary care for children, youth and adults".[4] The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health.[5][6][7][8] Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[9] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-face patient encounter may help encourage coordination.[9][10]

History[edit]

The concept of the "medical home" has evolved since introduction of the terminology by the American Academy of Pediatrics in 1967, which was envisioned at the time as a central source for all the medical information about a child, especially those with special needs.[11][12] Efforts by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician, to pursue new approaches to improve early childhood development in Hawaii in the 1980s[13] laid the groundwork for an Academy policy statement in 1992 that defined a medical home largely the way Sia conceived it: a strategy for delivering the family-centered, comprehensive, continuous and coordinated care that all infants and children deserve.[14] In 2002, the organization expanded and operationalized the definition.[13][15][16]

In 2002, seven U.S. national family medicine organizations created the Future of Family Medicine project to "transform and renew the specialty of family medicine."[17] Among the recommendations of the project was that every American should have a "personal medical home" through which to receive his or her acute, chronic, and preventive services.[17] The services should be "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians."[17]

As of 2004, one study estimated that if the Future of Family Medicine recommendations were followed (including implementation of personal medical homes), "health care costs would likely decrease by 5.6%, resulting in national savings of 67 billion dollars per year, with an improvement in the quality of the health care provided."[18] A review of the literature published the same year determined that medical homes are "associated with better health, ... with lower overall costs of care and with reductions in disparities in health."[19]

By 2005, the American College of Physicians had developed an "advanced medical home" model.[8][20] The model involved the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, medical care plans, "enhanced and convenient" access to care, quantitative indicators of quality, health information technology, and feedback on performance.[20] Payment reform was recognized as important to implement the model.[21]

IBM and other organizations started the Patient-Centered Primary Care Collaborative in 2006 to promote the medical home model.[22][23] As of 2009, its membership included "some 500 large employers, insurers, consumer groups, and doctors."[23]

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association — the largest primary care physician organizations in the United States — released the Joint Principles of the Patient-Centered Medical Home.[4] The principles listed were:

A survey of 3,535 U.S. adults released in 2007 found that 27% of the respondents reported having "four indicators of a medical home."[26] Furthermore, having a medical home was associated with better access to care, more preventive screenings, higher quality of care, and fewer racial and ethnic disparities.[26]

Important 2008–2010 developments concerning medical homes included:

Accreditation[edit]

The Accreditation Association for Ambulatory Health Care (AAAHC) in 2009 introduced the first accreditation program for medical homes to include an onsite survey. Unlike other quality assessment programs for medical homes, AAAHC Accreditation also mandates that PCMHs meet the Core Standards required of all ambulatory organizations seeking AAAHC Accreditation.

AAAHC standards assess PCMH providers from the perspective of the patient. The onsite survey is conducted by surveyors who are qualified professionals – physicians, registered nurses, administrators and others – who have first-hand experience with ambulatory health care organizations. The onsite survey process gives them an opportunity to directly observe the quality of patient care and the facilities in which it is delivered, review medical records and assess patient perceptions and satisfaction.

The AAAHC Accreditation Handbook for Ambulatory Health Care includes a chapter specifically devoted to medical home standards, including assessment of the following characteristics:

In addition, electronic data management must be continually assessed as a tool for facilitating the Accreditation Association medical home.

AAAHC Medical Home Accreditation also requires that Core Standards required of all ambulatory organizations seeking AAAHC Accreditation be met, including: Standards for rights of patients; governance; administration; quality of care; quality management and improvement; clinical records and health information; infection prevention and control, and safety; and facilities and environment. Depending on the services provided, AAAHC-Accredited medical homes may also have to meet Adjunct Standards such as anesthesia, surgical, pharmaceutical, pathology and medical laboratory, diagnostic and other imaging, and dental services, among others.[39]

Certification Program[edit]

In addition to its accreditation program for medical homes, the Accreditation Association for Ambulatory Health Care (AAAHC) is conducting a pilot Medical Home Certification program, which includes an onsite survey to evaluate an organization against the AAAHC Standards for medical homes. Full accreditation requires that organizations also be evaluated against all AAAHC Core Standards.[40]

Recognition Program[edit]

National Committee for Quality Assurance’s (NCQA) Physician Practice Connections and Patient Centered Medical Home (PPC-PCMH) Recognition Program emphasizes the systematic use of patient-centered, coordinated care management processes. It is an extension of the Physician Practice Connections Recognition Program, which was initiated in 2003 with support from organizations such as The Robert Wood Johnson Foundation, The Commonwealth Fund and Bridges to Excellence.[41] The PPC-PCMH enhances the quality of patient care through the well known and empirically validated Wagner Chronic Care Model, which encourages the health care system to use community resources to effectively care for patients with chronic illnesses through productive interactions between activated patients and a prepared practice team. Furthermore, it recognizes practices that successfully use systematic processes and technology leading to improved quality of patient care.[42]

With the guidance from the ACP, the AAFP, the AAP and the AOA the NCQA launched PPC-PCMH and based the program on the Medical Home Joint Principles developed by these organizations.[43]

If practices achieve NCQA’s PCMH Recognition they can take advantage of financial incentives that health plans, employers, federal and state-sponsored pilot programs offer. Furthermore, they may qualify for additional bonuses or payments.

In order to attain PPC-PCMH Recognition, specific elements must be met. Included in the standards are 10 “must-pass” elements:

ELEMENT 1A—Access and communication processes
The practice has written processes for scheduling appointments and communicating with patients.
ELEMENT 1B—Access and communication results
The practice has data showing that it meets the standards in element 1A for scheduling and communicating with patients.
ELEMENT 2D—Organizing clinical data
The practice uses electronic or paper-based charting tools to organize and document clinical information.
ELEMENT 2E—Identifying important conditions
The practice uses an electronic or paper-based system to identify the following in the practice’s patient population:
  • Most frequently seen diagnoses
  • Most important risk factors
  • Three clinically important conditions
ELEMENT 3A—Guidelines for important conditions
The practice must implement evidence-based guidelines for the three identified clinically important conditions.
ELEMENT 4B—Self management support
The practice works to facilitate self-management of care for patients with one of the three clinically important conditions.
ELEMENT 6A—Test tracking and follow-up
The practice works to improve effectiveness of care by managing the timely receipt of information on all tests and results.
ELEMENT 7A—Referral tracking
The practice seeks to improve effectiveness, timeliness and coordination of care by following through on critical consultations with other practitioners.
ELEMENT 8A—Measures of performance
The practice measures or receives performance data by physician or across the practice regarding:
  • Clinical process
  • Clinical outcomes
  • Service data
  • Patient safety
ELEMENT 8C—Reporting to physicians
The practice reports on its performance on the factors in Elements 8A.[43]

Scientific evidence[edit]

Recent peer-reviewed literature that examines the prevalence and effectiveness of medical homes includes:

International comparisons[edit]

In a study of 10 countries, the authors wrote that in most of the countries "health promotion is usually separate from acute care, so the notion[] of a... medical home as conceptualized in the United States... does not exist."[46] Nevertheless, the seven-country study of Schoen et al. found that the prevalence of medical homes was highest in New Zealand (61%) and lowest in Germany (45%).[6]

Controversy[edit]

Comparison with “gatekeeper” models[edit]

Some suggest that the medical home mimics the managed care “gatekeeper” models historically employed by HMOs; however, there are important distinctions between care coordination in the medical home and the “gatekeeper” model.[23][47] In the medical home, the patient has open access to see whatever physician they choose. No referral or permission is required. The personal physician of choice, who has comprehensive knowledge of the patient’s medical conditions, facilitates and provides information to subspecialists involved in the care of the patient. The gatekeeper model placed more financial risk on the physicians resulting in rewards for less care.[citation needed] The medical home puts emphasis on medical management rewarding quality patient-centered care.

Organizations criticizing the model[edit]

The medical home model has its critics, including the following major organizations:

Costs[edit]

Clinics compliant with principles of the patient-centered medical home may be associated with increase operating costs.[52]

Ongoing medical home projects[edit]

One notable implementation of medical homes has been Community Care of North Carolina (CCNC), which was started under the name "Carolina Access" in the early 1990s.[53] CCNC consists of 14 community health networks that link approximately 750,000 Medicaid patients to medical homes.[54] It is funded by North Carolina's Medicaid office, which pays $3 per member per month to networks and $2.50 per member per month to physicians.[54] CCNC is reported to have improved healthcare for patients with asthma and diabetes.[54] Non-peer-reviewed analyses cited in a peer-reviewed article suggested that CCNC saved North Carolina $60 million in fiscal year 2003 and $161 million in fiscal year 2006.[54][55][56] However, an independent analysis asserted that CCNC cost the state over $400 million in 2006 instead of producing savings.[57] More recent analyses show that the program improved the quality of care for asthma and diabetes patients significantly, reducing emergency department and hospital use that produced savings of $150 million in 2007 alone.[58]

The Rhode Island Chronic Care Sustainability Initiative (CSI-RI) is a community-wide collaborative effort convened in 2006 by the Office of the Health Insurance Commissioner to develop a sustainable model of primary care that will improve the care of chronic disease and lead to better overall health outcomes for Rhode Islanders.[59][60] CSI-RI is focused on improving the delivery of chronic illness care and supporting and sustaining primary care in the state of Rhode Island through the development and implementation of the patient-centered medical home. The CSI-RI Medical Home demonstration officially launched in October 2008 with 5 primary care practices and was expanded in April 2010 to include an additional 8 sites.[59][61] Thirteen primary care sites, 66 providers, 39 Family Medicine residents, 68,000 patients (46,000 covered lives), and all Rhode Island payers are participating in the demonstration. Further, its selection to participate in the Centers for Medicare and Medicaid Services' Multi-Payer Advanced Primary Care Practice demonstration, CSI-RI is one few medical home demonstrations in the nation with virtually 100% payer participation. Since the start of the demonstration, CSI-RI sites have implemented a series of delivery system reforms in their practices, aimed at becoming patient-centered medical homes, and in turn receive a supplemental per-member-per-month payment from all of Rhode Island's insurers. Each participating practice site also receives funding from participating payers for an on-site nurse care manager, who can work with all patients in the practice, regardless of insurance type or status. All 5 original pilot sites achieved NCQA level 1 PPC-PCMH recognition in 2009, and all 8 expansion sites achieved at least level 1 PPC-PCMH recognition in 2010. As of December 2010, all of the pilot sites and two of the expansion sites have been recognized by NCQA as level 3 patient-centered medical homes.

Projects evaluating medical home concepts[edit]

The Agency for Healthcare Research and Quality offers grants to primary care practices in order for them to become patient-centered medical homes. The grants are designed to increase the evidence base for these types of transformations.[62]

As of December 31, 2009, there were at least 26 pilot projects involving medical homes with external payment reform being conducted in 18 states.[63] These pilots included over 14,000 physicians caring for nearly 5 million patients.[63] The projects are evaluating factors such as clinical quality, cost, patient experience/satisfaction, and provider experience/satisfaction.[64] Some of the projects underway are:

In 2006, TransforMED announced the launch of the National Demonstration Project aimed at transforming the way primary care is delivered in our country. The practice redesign initiative, funded by the AAFP, ran from June 2006 to May 2008. It was the first and largest “proof-of-concept” project to determine empirically whether the TransforMED Patient-Centered Medical Home model of care could be implemented successfully and sustained in today’s health care environment. More specifically, the project served as a learning lab to gain better insight into the kinds of hands-on technical support family physicians want and need to implement the PCMH model of care. Learn more about National Demonstration Project

Between 2002 and 2006, Group Health Cooperative made reforms to increase efficiency and access at 20 primary care clinics in western Washington. These reforms had an adverse impact, increasing physician workload, fatigue, and turnover. Negative trends in quality of care and utilization also appeared. As a result, the Group Health Research Institute developed a patient-centered medical home model in one of the clinics. By increasing staff, patient outreach and care management, the clinic reduced emergency department visits and improved patient perceptions of care quality.[70]

The Role of PCMH and Accountable Care Organizations (ACO) in the Coordination of Patient Care[edit]

There are four core functions of primary care as conceptualized by Barbara Starfield and the Institute of Medicine. These four core functions consist of providing “accessible, comprehensive, longitudinal, and coordinated care in the context of families and community.”[10]

In the PCMH model, the integration of diverse services that a patient may need is encouraged. This integration which also involves the patient in interpreting the streams of information and working together to find a plan that fits with the patient’s values and preferences is under-recognized and under-appreciated.[71]

Appropriate coordinated care depends on the patient or the population of patients and to a large extent, the complexity of their needs. The challenges involved with facilitating the delivery of care increases as the complexity of their needs increase. These complexities include chronic or acute health conditions, the social vulnerability of the patient, and the environment of the patient including the number of providers involved in their care. Other factors that may play a role in the patient’s coordination of care include their preferences and their ability to organize their own care. The increases in complexity may overwhelm informal coordinating functions requiring a care team that can explicitly provide coordinated care and assume responsibility for the coordination of a particular patient’s care.[10]

According to the ACO, care coordination achieves two critical objectives—high-quality and high-value care. ACOs can build on the coordinated care provided by the PCMHs and ensure and incentivize communications between teams of providers that operate in various settings. ACOs can facilitate transitions and align the resources needed to meet the clinical and coordinated care needs of the population. They can develop and support systems for the coordination of care of patients in non-ambulatory care settings. Furthermore, they can monitor health information systems and the timeliness and completeness of information transactions between primary care physicians and specialists. The tracking of this information can be used to incentivize higher levels of responsiveness and collaborations.[10]

See also[edit]

References[edit]

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External links[edit]