The American Academy of Pediatrics introduced the medical home concept in 1967, initially referring to a central location for maintaining the medical records of a child. In 2002, the definition was expanded to incorporate the characteristics of accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally sensitive care. Since 2002, both the American College of Physicians (2006) and the American Academy of Family Practice (2004) adopted their own variations of the AAP definition and in February, 2007, all three of these professional organizations joined with the American Osteopathic Association to issue a consensus document outlining joint principles of a Patient-Centered Medical Home.
The consensus statement defines the Patient Centered Medical Home (PC MH) as an approach to providing comprehensive primary care for children, youth and adults. The PC MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians and health care providers, and when appropriate, the patient’s family.
Personal Physician: A core tenet of the PCMH model is that each patient has a clearly identified personal physician who is responsible and available to the patient as the entry point to their interactions with the health care delivery system. Rather than imply use of a gatekeeper, this principle attempts to assure that there is one individual who is trained to provide first contact, continuous, and comprehensive care and who is ultimately responsible for making sure that all support processes of care are meeting the needs of the patient. This issue presents significant challenges for many primary care practices, such as in an FQHC environment where it is not uncommon for patients to be scheduled to see any available provider.
Physician Led Care Teams: While this principle has caused some concern because it is being interpreted by some groups as physician-centric, the focus of this principle is on a team approach to care delivery. In a rural state such as West Virginia, the care team may actually be led on a day to day basis by an advanced practice provider rather than a physician. A patient-centered medical home cannot be achieved in practice without fully leveraging the skills of the entire care team. This suggests the possible need for retraining as well as coaching to find ways to match all tasks to staff with their skill sets, using staff with the lowest level of training allowed by licensure in the State. In this way, the use of the scarcer and more costly provider resources can be maximized, but this also means fundamental changes in who performs certain tasks, such as foot exams or self management support. Incentives alone will not drive these changes as this will require training as well as investment on the part of the practice to redefine the roles of the care team.
Whole Person Orientation and Coordination of Care: Two of the more challenging aspects of the medical home model are the principles of whole person orientation and ensuring coordination and integration of care across all health care needs, all stages of life, and all elements of the health care system. To effectively accomplish these objectives, the primary care practice must have supporting systems linked to the evidence base (such as registries and electronic health record systems) that enables the care team to address preventive and chronic care needs at the same time a patient presents with an acute problem. This is currently not practical in a paper based environment. The coordination of care across the continuum of the health care system is equally challenging in an environment that relies on people to provide communication from specialists, hospitalists, or emergency room physicians back to the primary care provider. There are tremendous challenges in managing the handoffs that result when patients move throughout the health care system. In the new environment as medical homes, primary care practices are being expected to provide at least part of the solution for these system design issues. This care coordination is critical with the evidence base suggesting that it should result in reductions of unnecessary ED utilization, unnecessary referrals and a reduction of ambulatory care sensitive admissions. The economics within the primary care practice, however, are cause for concern. Without additional support, many practices do not have the resources or volume of patients to justify full time care coordinators or case managers. These practices will not only need linkages to a network of providers that crosses the continuum; they will also need to leverage new relationships with other resources in the community in order to support the economics of the care coordination role.
Enhanced Access: A goal of the medical home is to assure that patients can get care when needed and in the manner needed. This means migrating practice scheduling systems to a system of open access and same day appointments. It means providing clinician access after-hours as well as timely telephone response and use of alternative communication methods such as email. Enhancing access is an area where much of the savings can be derived at a system level. If patients know who their physician is and can readily access that individual, inappropriate ED utilization will be dramatically reduced, bring with it lower system costs. Patients will also be more likely to have problems addressed before they worsen, again placing less of a burden on the costlier components of the health care system. Once again, however, enhancing access requires profound changes at the practice level and possible new relationships and resources to manage the afterhours care needs.
Quality and Safety: Although most primary care providers will maintain that they are concerned about quality and safety, the principles of a patient-centered medical home attempt to define specific aspects of quality that must be addressed. These include using an evidence-based approach to care and appropriate decision-support tools, shared decision-making with patients, engagement in quality improvement activities, appropriate use of technology, and measuring performance. Once again, incentives and regulatory mandates will not be sufficient to achieve this aim. These changes will require new training, new systems to facilitate safety practices, training in quality methods, and systems for measuring and reporting performance.
Payment Models to Support the Medical Home: A final principle of the medical home recognizes that changes to the fundamental care system will not be achieved unless there are changes in reimbursement to support the new care model. A structural problem exists in the health care system that results in a current lack of alignment of incentives to support this model of care. There are many examples of how this plays out in practice.
It is well established that prevention services will lead to improved health status. However, the linkage in terms of return on investment has been historically weak. Therefore, many routine preventive services that are inherent in the whole patient principle of the medical home are not adequately funded. The medical home model requires providers to begin collecting clinical data in formats that are easy to retrieve for population analysis. This requires investment in new decision support systems such as clinical registries, local computers and printers, staff training and data entry time. The medical home model places an emphasis on empowering patients and building self activation capacity. That requires time of the care team to deal with the psychosocial issues and use techniques such as motivational interviewing methods to encourage better lifestyle choices. These services are most often not covered within existing payment methodologies. In some cases, there are actually disincentives precluding such investments. Overall, the work of the medical home requires investment of time and resources at the primary care level. As primary care practices implement the medical home model they start to influence utilization and health care outcomes. Savings are produced but they tend to be downstream in the process and accrue to the payers and the system at large. As a result, a cost shift is necessary from downstream in the health care dollar pool to the upstream primary care component. Specific support is encouraged for use of technology, for the role of care coordination, for the work of non-physician members of the care team, and for work that falls outside of face to face encounters.
