Medical home

From Clinfowiki
Jump to: navigation, search

The medical home or patient centered medical home is a holistic approach to primary care that treats the whole person, not just the symptom or disease that brings you into a doctor's office. It is a team of providers, lead by a personal physician focused on the whole patient, coordinating and integrating all aspects of the healthcare system including chronic disease management, long term care, hospital and specialty care and hospice or end of life care.

The patient's primary physician is responsible for all decisions made about your care, which gives the patient one person to turn to with questions or concerns about their health. The system is designed to prevent many doctors flying blind when trying to coordinate a patient's care. If a patient is seeing several specialists, a primary care physician and two or three pharmacists there is no guesswork involved for any of the participants in choosing the most appropriate interventions.

The Medical Home concept was introduced in 1967 by the American Academy of Pediatrics, referring to a centralized location for a child's medical record. In 2002, the concept was expanded to " accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care

"1 A standardized, interoperable electronic health record will be important to the success of a medical home, as coordinating and integrating many different providers and stakeholders in the healthcare needs of each patient will require accurate, timely and complete information to truly be successful.

1Joint Principles of the Patient Centered Medical Home, American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA), February 2007,

Submitted by (Nicole Newland)

Updates from recent articles on Medical Home

Since the creation of the Medical Home concept, several studies have illuminated and attempted to define a pathway to transforming primary care medical practice into the medical home. Despite ambitions for rapid change, many researchers find that the path to change may be strewn with obstacles that can end transformation before it has a chance to slowly change the way health care is delivered.

An independent evaluation team, contracted with the American Academy of Family Physicians, led by Paul A. Nutting, MD summarized their findings in May 2009 in The Annals of Family Medicine 1 . Nutting’s group studied both facilitated (making use of a change facilitator individual and consultation from expert panels) and self-directed physician practices. Before final analysis of the National Demonstration Project was complete, Nutting et al stated that “…current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology and are seriously undercapitalized.”

This group sees that the total transformation of practice required to implement the medical home is far more complex than the incremental plan-do-study-act improvements to largely undisturbed traditional models of patient care. Incomplete or inefficient work processes are magnified by rapid change and may precipitate staff burnout, attrition and even retreat from the change process, according to the study. “Change fatigue”, from relentless work to change virtually every process, job description and pattern in the practice, may also be precipitated by the lack of coherent and interoperable health information technology available to the outpatient practice, which seldom has the ability to create custom solutions to information problems.

Nutting et al recommend several health policies, to provide the qualitative underpinnings for true change management. These include:

1) Assure Adequate Financial Resources—additional capital will be required by practices not only for IT and hardware, but for additional personnel, training time, and reduced patient loads while the practice is changing its way of providing care. 2) Tailor the Approach to the Practice—each practice must create its own pathway and ultimate goals; “the decisions of what and how and when to change must be theirs”. 3) Assist Physicians With Their Personal Transformations—changing to a team approach, from the traditional authoritarian approach, will require self-development of physicians and ongoing support of the new kinds of work relationships that will be required, with staff and patients. Time must be provided for workshops, learning to use chronic care models, using evidence at the point of care, developing of leadership skills and a host of other aspects of this major change, according to the study. 4) National Committee for Quality Assurance should modify its PCMH-Recognition Process—these researchers see that it will require more than three years to achieve this kind of change. Researchers state that “We fear the details of the recognition process may have reached premature closure, however, before the rich data have emerged from the NDP and other current demonstrations.”

Several of the same researchers published another paper, Defining and Measuring the Patient-Centered Medical Home, 2 which offers more definition and study of the medical home concept in practice. They state that the PCMH is four things:

1) The fundamental tenets of primary care—first contact access, comprehensiveness, integrations/coordination, and relationships involving sustained partnerships 2) New ways of organizing practice 3) Development of practices’ internal capabilities 4) Related health care system and reimbursement strategies

Researchers state that “Primary care in the US is under-resourced compared to specialty care” and develop their argument that there may be unintended negative consequences from the attempt at rapid change in primary care, from many causes: the cost to change practice will be incurred at the practice level, but the benefits may accrue outside the practice (in the greater health care system or to the patients directly, for example). Researchers also conclude that a narrow and short term approach may prevent the kind of transformative change that PCMH is intended to foster.

Are medical students now in school being taught this transformative ideal? Published in late 2011, Joo and researchers 3 surveyed 359 first through fourth year medical students in two schools that did not have comprehensive medical home curricula. 40.9% of students surveyed were still aware of the concept, but a troubling 29.6% “believed that primary care physicians function as gatekeepers [preventing access to certain forms of care or limiting care] in the PCMH model”.

The gatekeeper design of managed care, which has largely been scrapped in the last decade and dates to the 1990’s, was an attempt to limit access to care as a cost management technique. PCMH is a care design that attempts to organize care at the primary care level, so that the patient’s care is comprehensive and coordinated, preventing unnecessary repetition of work and also ensuring that care is complete and in-depth, and that the patient understands and is well-educated and apprised of needed self-care as well.

Another set of researchers, Rittenhouse et al 4, looked at policy and research agendas for the PCMH and raised key questions that tend to be lost in the shuffle of standards and deadlines. This group stated that health care safety, although identified as an urgent goal of the Institute of Medicine’s aims for healthcare improvement for 21st century health care, has been largely limited to prescribing errors and medication safety, to date. According to this group, safety measures in the ambulatory care setting have a ways to go. Many measures of health improvement are carried out at the national or state level with large patient populations and are hard to see at the level of the individual practice.

Rittenhouse et al also see unintended consequences for the PCMH. “…increased reliance on technologies to improve efficiency might ultimately result in less human interactions and lower patient satisfaction. Increased attention on chronic care management might divert resources from delivering high quality care for acute illness. “They go on to write: “Because only a small proportion of activities can be measured, there is a danger that unmeasured activities will be neglected to the detriment of patients.”

This raises the question of the Heisenberg Uncertainty Principle: will the act of measuring (and re-measuring) certain aspects of health care change it, or will failing to measure other aspects of health care have an impact on those aspects as well? Another way to think about this: when looking at the consequences of economic incentives, whether they are within the general tax code or within the structure of incentive payments for technological change, why are we changing and are we changing the right things?

1 Nutting PA, Miller WL, Crabtree BF, et al. Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home. Annals of Family Medicine, Vol.7, No.3 pp 254-260.

2 Stange KC, Nutting PA, Miller WL, et al. Defining and Measuring the Patient-Centered Medical Home. J Gen Intern Med 2010. Jun; 25(6):601-12.

3 Joo P, Younge R, Jones D, et al. Medical Student Awareness of the Patient-centered Medical Home. Fam Med 2011. Nov-Dec; 43 (10): 696-701.

4 Rittenhouse DR, Thom DH, Schmittdiel, JA. Developing a Policy-Relevant Research Agenda for the Patient-Centered Medical Home: A Focus on Outcomes. J Gen Intern Med. 2012 June;25(6); 593-600.

The above updates submitted by Susan J. Bliss