Medical home

Medical home

The medical home,[1] also known as the patient-centered medical home (PCMH), is defined as "an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient’s family".[2] The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health.[3][4][5][6]

Contents

History

The concept of the medical home has evolved since its introduction by the American Academy of Pediatrics in 1967.[7] In 1992 that Academy published a policy statement defining a medical home, and in 2002 they expanded and operationalized the definition.[7][8][9]

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."[6][10] 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.[10] The services should be "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians."[10]

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."[11] 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."[12]

By 2005, the American College of Physicians had developed an "advanced medical home" model.[6][13] 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.[13] Payment reform was recognized as important to implement the model.[14]

IBM and other organizations started the Patient-Centered Primary Care Collaborative in 2006 to promote the medical home model.[15][16] As of 2009, its membership included "some 500 large employers, insurers, consumer groups, and doctors."[16]

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.[2] The principles listed were:

  • 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."
  • Care is coordinated and/or integrated, for example across specialists, hospitals, home health agencies, and nursing homes.
  • Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making, information technology, a voluntary recognition process, quality improvement activities, and other measures.
  • Enhanced access to care is available (e.g., via "open scheduling, expanded hours and new options for communication").
  • Payment must "appropriately recognize[s] the added value provided to patients who have a patient-centered medical home." For instance, payment should reflect the value of "work that falls outside of the face-to-face visit," should "support adoption and use of health information technology for quality improvement," and should "recognize case mix differences in the patient population being treated within the practice."

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."[17] 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.[17]

Important 2008–2010 developments concerning medical homes included:

  • The Accreditation Association for Ambulatory Health Care (AAAHC) began accrediting medical homes in 2009 and is the only accrediting body to conduct on-site survey for organizations seeking Medical Home accreditation.[18]
  • The National Committee for Quality Assurance released Physician Practice Connections–Patient-Centered Medical Home (PPC-PCMH), a set of voluntary standards for the recognition of physician practices as medical homes.[19]
  • In answering a 2008 survey from the American Academy of Family Physicians, then-presidential candidate Barack Obama wrote "I support the concept of a patient-centered medical home"[20] and that as president he would "encourage and provide appropriate payment for providers who implement the medical home model".[15][16][20]
  • The New England Journal of Medicine published recommendations for the success of medical homes that included increased sharing of information across health care providers, the broadening of performance measures, and the establishment of payment systems that share savings with the physicians involved.[21]
  • Guidance for patients and providers on operationalizing the Joint Principles was made available.[22]
  • The American Medical Association expressed support for the Joint Principles.[23]
  • A coalition of "consumer, labor and health care advocacy groups" released nine principles that "allow for evaluation of the medical home concept from a patient perspective."[24][25]
  • Initial findings of a medical home national demonstration project of the American Academy of Family Physicians were made available in 2009.[26] A final report on the project, which began in 2006 at 36 sites, will be published in 2010.[dated info][26][27]
  • By 2009, 20 bills in 10 states had been introduced to promote medical homes.[28]
  • In 2010, 7 key health information technology domains were identified as necessary for the success of the PCMH model: telehealth, measurement of quality and efficiency, care transitions, personal health records, and, most important, registries, team care, and clinical decision support for chronic diseases.[29]
  • On January 31, 2011, the National Committee for Quality Assurance (NCQA) released new standards for its Patient-Centered Medical Home (PCMH) program. The new standards call on medical practices to be more patient-centered, and reinforce federal “meaningful use” incentives for primary care practices to adopt health information technology.[30]

Scientific evidence

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

  • In 2007, researchers from the Centers for Disease Control and Prevention published a study involving interviews with 5400 parents; the authors concluded that continuous primary care in a medical home was associated with higher rates of vaccinations for the respondents' children.[3]
  • Schoen and colleagues (2007) surveyed adults in seven countries, using the answers to four questions to categorize the respondents as having a medical home or not.[4] Having a medical home was associated with less difficulty accessing care after hours, improved flow of information across providers, a positive opinion about health care, fewer duplicate tests, and lower rates of medical errors.[4]
  • A review of 33 articles by Homer et al. on medical homes for children with special health care needs published in 2008 "provide[d] moderate support for the hypothesis that medical homes provide improved health-related outcomes."[5]
  • A 2008 review by Rosenthal determined that peer-reviewed studies show "improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home."[6]
  • In a survey of parents or legal guardians of children with special health care needs published in 2009, 47.1% of the children had a medical home, and the children with a medical home had "less delayed or forgone care and significantly fewer unmet needs for health care and family support services" than the children without a medical home.[31]
  • Reid et al. (2010) showed within the Group Health system in Seattle that a medical home demonstration was associated with 29% fewer emergency visits, 6% fewer hospitalizations, and total savings of $10.30 per patient per month over a twenty-one month period.[32]

International comparisons

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."[33] 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%).[4]

Controversy

Comparison with “gatekeeper” models

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.[16][34] 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

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

  • The American College of Emergency Physicians expresses cautions such as "a shifting of financial and other resources to support the PCMH model could have adverse effects on sectors of the health care system" and "there should be proven value in health care outcomes for patients and reduced costs to the health care system before there is widespread implementation of this model."[35]
  • The American Optometric Association is concerned that medical homes "may restrict access to eye and vision care" and requests "that optometry be recognized as a principal provider of eye and vision care services within the PCMH"[36][37]
  • The American Psychological Association states that Congress should ensure that "careful consideration is paid to the role of psychologists and non-physician providers in the medical home model, which should be more appropriately named the 'health home model'."[38]

Ongoing medical home projects

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.[39] CCNC consists of 14 community health networks that link approximately 750,000 Medicaid patients to medical homes.[40] 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.[40] CCNC is reported to have improved healthcare for patients with asthma and diabetes.[40] 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.[40][41][42] However, an independent analysis asserted that CCNC cost the state over $400 million in 2006 instead of producing savings.[43]

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.[44][45] 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.[44][46] 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

As of December 31, 2009, there were at least 26 pilot projects involving medical homes with external payment reform being conducted in 18 states.[47] These pilots included over 14,000 physicians caring for nearly 5 million patients.[47] The projects are evaluating factors such as clinical quality, cost, patient experience/satisfaction, and provider experience/satisfaction.[48] Some of the projects underway are:

  • Division B, Section 204 of the Tax Relief and Health Care Act of 2006 outlined a Medicare medical home demonstration project.[49] This three-year project will involve care management reimbursement and incentive payments to physicians in 400 practices in 8 sites.[28][49] It will evaluate the health and economic benefits of providing "targeted, accessible, continuous and coordinated, family-centered care to high-need populations."[49] As of July 2009, however, the project had not yet started recruiting practices.[50]
  • A UnitedHealth Group medical home pilot in Arizona involving 7,000 patients and 7 medical groups began in 2009 and is scheduled to end in 2011.[52]
  • The state of Maine provided $500,000 in 2009 for a pilot project in 26 practices.[53]
  • The New Jersey Academy of Family Physicians and Horizon Blue Cross and Blue Shield of New Jersey implemented a pilot project in March 2009. This project is ongoing and involves more than 60 primary care practice sites and 165 primary care physicians. Specialties include family medicine/practice, internal medicine and multi-specialties in which 50% or more of the care provided is primary care.[citation needed]
  • The Texas Medical Home Initiative, a multi-stakeholder primary-care driven organization, has launched a two year pilot involving 7 primary care practices in North and East Texas. This project involves 45 physicians and 75,000 patients. Services to the practices include practice coaching, a patient registry system, assistance with developing practice agreements with specialty practices to build the "medical neighborhood".

See also

  • Orphan patient
  • The Patient: Patient-Centered Outcomes Research (medical journal)

References

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