No place like home
The patient-centered medical home is an approach that could achieve patient and physician satisfaction, plus reform, all in one
Personal. Integrated. High quality. Comprehensive. Convenient. Cost-effective. Most patients would use these words when describing their vision of ideal patient care. The field of medicine, however, is littered with obstacles to this archetype, from office organization to payment structure to time. Recently, however, an older idea is being revived with the advent of new technology and new motivation to reform health care delivery around a primary care model that works for patients and physicians.
It has been said that the patient-centered medical home is what patients think their doctor’s office has been doing all along – that they are guided throughout their life through all aspects of care, and that their doctors communicate with each other to coordinate care and monitor their status. Reality in a fee-for-service system, where primary care physicians are strapped for time, is that care is usually episodic. Unless a patient is in the office, they are seldom on the radar.
This dilemma was observed at least as early as 1967, when pediatrics leadership coined the term “patient-centered medical home.” The concept could not take flight as the resources necessary were not yet developed. The birth and subsequent growth and implementation of the electronic medical record (EMR) and other communications technologies has more recently created an environment conducive to the adoption of the medical home model, said James G. Slawson, MD, GME ’91, Assistant Professor and Director of Clinical Activities in Family and Community Medicine at The Medical College of Wisconsin. As a result, the approach is viewed by many as a solution to some of the issues of access, continuity of care, chronic care management, cost, and patient and physician satisfaction present in the current health care system.
James G. Slawson, MD, GME ’91, Assistant Professor and Director of Clinical Activities in Family and Community Medicine at The Medical College of Wisconsin, oversees a patient encounter with resident Ketan Morker, MD, and medical student Sharon Rikin, Class of 2011, at the College’s St. Joseph Family Medicine Residency site. The site’s application for level III certification as a patient-centered medical home is under review by the National Committee for Quality Assurance.
“In this country, we have expensive health care, inequitable distribution of that health care and a looming shortage of primary care providers, which is just going to make it worse,” said Rodney A. Erickson, MD ’81, a family practitioner in Tomah, Wis., and a Director of the Wisconsin Academy of Family Physicians, which is advocating for the large-scale realization of the medical home concept. “The public is saying ‘we want higher quality health care at a lower cost,’ and we see the patient-centered medical home as a vehicle to provide that.”
At its heart, a patient-centered medical home is an approach in which care is coordinated by the primary care physician throughout the patient’s life, where all parties are working and communicating in sync, where patients have convenient access to care, and where evidence informs decision-making.
Rodney A. Erickson, MD ’81, discusses joint care with a patient. As a Director of the Wisconsin Academy of Family Physicians, Dr. Erickson has seen enthusiasm grow for the patient-centered medical home concept.
In 2007, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association arrived at a consensus definition and endorsement of the patient-centered medical home. Their Joint Principles describe the characteristics required for the approach to work and serve as the guidelines used by such agencies as the National Committee for Quality Assurance (NCQA) to establish benchmarks and certification for medical home implementation.
The three residency sites overseen by the Medical College’s Department of Family and Community Medicine are deeply engaged in the practice principles essential to the patient-centered medical home and requisite for NCQA certification. The NCQA is currently reviewing the applications for level III (top) medical home certification for the St. Joseph and the Columbia St. Mary’s family medicine residency sites. The application for the Waukesha site will be submitted shortly.
The opportunity to seek level III certification is the result of ongoing advances in the practices that are consistent with medical home ideals. One of the department’s earliest initiatives engaged its EMR in an outcomes study that addressed immunization rates.
When the project began in 2004, the state of Wisconsin set a goal for 80 percent of children to be fully immunized by the age of 2. Dr. Slawson’s clinic used its EMR to define a complete population of 2-year-old children and their vaccination status. Their rates were about 45 percent, typical for a Milwaukee County practice. Instead of waiting for patients to come in for a well-child visit, the team assigned a nurse to the project who checked the immunization status of any child in the age range entering the clinic for any reason and followed up with appropriate vaccinations. They also created a registry of children who were not up to date and had nurses call parents to set up immunization appointments; sometimes a community nurse even made home visits.
“This initiative has given us rates over 90 percent,” Dr. Slawson said. “Three times we have been recognized by the American Academy of Family Physicians. It’s not necessarily for our high rates – it’s for how we changed and implemented this project. It’s an example of using the EMR to create a registry, then readjusting your office practice with the patient at the center.”
Just as technology has helped drive the patient-centered medical home, so has a renewed emphasis on the importance of primary care. Dr. Slawson observes how preventive services can fall through the cracks when patients manage their own care and visit specialists without a central physician providing coordination and communication. It also can result in duplication of services, labs or medications, which is not optimal for the patient.
A patient-centered medical home also places a premium on availability, so the offices are usually structured to include after-hours and weekend scheduling as well as maintaining a percentage of open spots to allow for same-day visits. This helps reduce the number of patients visiting emergency departments and urgent care clinics for non-emergencies and allows patients to see their home doctor.
“It’s called patient-centered because you’re looking at how you practice medicine from the patient’s perspective,” Dr. Slawson said. “Traditionally, it has been from the provider’s perspective to maximize the efficiency of the doctor. Here, you’re really trying to maximize meeting the needs of the patient.”
The policy and procedural changes required for a functional patient-centered medical home permeate the entire practice. Duties change, tasks are added and accountability increased in a monumental restructuring of practice operations and philosophy. But these are all value-added investments, advocates agree.
Dr. Erickson said the Wisconsin Academy of Family Physicians has endorsed the medical home approach because of the merit it has for patients and the value it holds for physicians.
“First, if we can implement it fully as we see it, I think it will allow us to provide the care that we have long sought to provide people,” he said. “Professionally, we’ll be able to fulfill our mission the way we’ve hoped. Second, a component of the patient-centered medical home provides reimbursement for care management, not just fee for service. There has to be change in how we are reimbursed to make it work in the long run.”
Providing proper payment to physicians who are performing additional services like answering e-mail, talking to specialists or scheduling fewer appointments, is a challenge in the medical home approach that is beginning to be met creatively. Kenneth J. Phenow, MD ’92, MPH, is Senior Medical Director for CIGNA HealthCare of Texas and Oklahoma. CIGNA currently has the first commercial payer-sponsored medical home in Texas, consisting of a group of 45 practices in north Texas. They have an interoperable EMR and 20 clinical protocols around chronic diseases.
CIGNA funded upfront the hiring of a care coordinator for the group and provides the offices with predictive models, gaps in care data, specialist quality and efficiency evaluations and other data to guide care. At the end of this two-year pilot program, the level of medical cost improvement will fund a shared savings bonus pool that will be distributed to the client and to the group based on meeting certain quality indicators. In this model, patient and physician satisfaction would improve, medical costs would be reduced, and physicians could earn compensation for their effort, Dr. Phenow said.
“Primary care physicians provide much more cost-effective quality care over a person’s lifetime,” he said. “We also feel it’s good to get the best value we can for the health care dollar. We see this medical home approach can really do this, and that’s our responsibility to our clients – employers who purchase health coverage for their employees and are the ultimate payers of health care costs.”
In other parts of the country, pilot patient-centered medical homes have already shown results. The Geissinger Clinic’s medical home in Pennsylvania, for example, saw a 14 percent reduction in hospital admissions overall, an 18.5 percent reduction in hospital readmissions and a 9 percent total medical costs savings over 24 months, equaling nearly $4 million after infrastructure investment. The Group Health Cooperative of Puget Sound in Washington piloted a medical home that was budget neutral after investment and experienced a 29 percent reduction in emergency visits and an 11 percent reduction in hospital admissions.
With health care costs growing at an unsustainable rate of about 8 percent per year, the value realized by the patient-centered medical home is particularly poignant, and underscores why national payers like CIGNA are interested in partnering with providers for a remedy.
“Patient-centered medical home is not the panacea, but it’s a solution,” Dr. Phenow said. “The bottom line is we’re going to get higher quality, lower cost, with increased patient satisfaction. The medical home is not a place – it’s an approach to improve care. It will take care of so many problems in the current system: fragmentation, lack of coordination, quality and affordability and really improve the patient experience.”
As an OB/GYN in the Affinity Medical Home in Kaukauna, Wis., Andrew Weiss, MD ’94, can attest to how the approach can directly benefit patients. A patient he knew with chronic back pain, and more recent pelvic pain, was evaluated and referred to spine specialists who did not find a specific cause. Subsequently, she saw a physical therapist on the medical home team who asked further questions about her symptoms, then consulted Dr. Weiss about a possible connection. He spoke with the woman’s primary doctor, who was able to see her that day, and identified pelvic prolapse as the primary cause of her worsening low back pain and planned management accordingly. The collaboration was timely and the continuity seamless, he said.
“The medical home model is most notable for the culture of proactivity,” Dr. Weiss said. “When we practice being a team, focused on patients during all steps from access to the visit to follow up, we become more confident of the process, with no time wasted wondering whether the system will do its job.”
Patients notice the continuity when they schedule appointments or share their history with the nurse, he said, and they report being more satisfied with the team as a whole, rather than perceiving gatekeepers or redundant steps.
“The medical home is absolutely a good answer to most of the problems with access, cost and error reduction, and continuity of care,” Dr. Weiss said. “Its implementation simply requires an attitude of cooperation and service and puts leadership where it belongs.”
What’s in a home?
Joint Principles of the Patient-Centered Medical Home in brief:
- 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 at the practice level that collectively takes responsibility for the patient’s care.
- Whole person orientation – the personal physician provides for all the patient’s health care needs or arranges care with other appropriate professionals across all stages of life and type of care.
- Care is coordinated and/or integrated across all elements of the complex health care system and the patient’s community.
- Quality and safety are hallmarks.
- Enhanced access to care is available through open scheduling, expanded hours and new communications options.
- Payment appropriately recognizes the added value provided to patients.
Having a National Committee for Quality Assurance (NCQA) certified patient-centered medical home is good for patients and physicians in the Medical College’s Department of Family and Community Medicine, but it’s also good for training. As an academic medical center, it is important to be on the leading edge, and being an early adopter of the medical home concept will give Medical College family medicine residents experience in an emerging environment.
“Clearly, the patient-centered medical home is going to be part of the future, and our residents need to be able to understand the concept now and actually be able to practice it now,” said Jim Slawson, MD, GME ’91, Assistant Professor and Director of Clinical Activities in Family and Community Medicine. “It has to be part of what they do.
“One of the challenges in medical training, and this is true for every specialty, is that the way health care is practiced changes rapidly. Your residents have to be on the cutting edge when they start, because if they are not, they are way behind to begin with. It does require you do some predicting of what will be important. We are predicting that the patient-centered medical home is going to be a big deal.”
Having a fully functioning patient-centered medical home is also an advantage for recruiting the most qualified residents, Dr. Slawson said.
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