Medical home

From Wikipedia, the free encyclopedia

This article or section deals primarily with the United States and does not represent a worldwide view of the subject. Please improve this article or discuss the issue on the talk page.

The basic premise of the medical home concept is continual care that is managed and coordinated by a personal physician with the right tools will lead to better health outcomes.

Contents 1 Introduction 2 What Brought Us Here? 3 Why Is This Concept Important? 4 How Is This Not a Gatekeeper Model? 5 Is Anyone Already Doing This? 6 See also 7 References 8 External links

[edit] Introduction

Central to the Medical Home approach is the premise that patient-centered care requires a fundamental shift in the relationship between patients and their primary care physicians. There must be a higher degree of personalized care coordination, access beyond the acute care episode, and identification of key medical and community resources to meet the patients’ needs. However, the widespread adoption of information technology for care management and quality improvement along with adequate payment methods are essential. In the long run, the Medical Home is likely to result in savings to patients, employers, and health plans. Increasing the emphasis on primary care could produce large dividends throughout the health care system.

The concept of the Medical Home has evolved since its introduction by the American Academy of Pediatrics in 1967. It has gone from a specific place to receive care for children with chronic disease, to an entire system of providing care for all Americans. This concept shifts the paradigm from episodic acute care to a continuous comprehensive model.

The basic premise of the medical home concept is care that is managed and coordinated by a personal physician with the right tools will lead to better outcomes.

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association—the leading primary care physician organizations—released the Joint Principles of the Patient-Centered Medical Home. In this document they state the characteristics of the Patient Centered Medical Home:

• Personal Relationship: Each Patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
• Team Approach: The Personal Physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing patient care.
• Comprehensive: The personal physician is responsible for providing for all the patient’s health care needs at all stages of life or taking responsibility for appropriately arranging care with other qualified professionals.
• Coordination: Care is coordinated and integrated across all domains of the health care system, facilitated by registries, information technology, health information exchange and other means to assure that patient get the indicated care when and where they want it.
• Quality and Safety: Quality and Safety are hallmarks of the medical home. This includes using electronic medical records and technology to provide decision-support for evidence-based treatments and patient and physician involvement in continuous quality improvement.
• Expanded Access: Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, physicians, and practice staff.
• Added Value: Payment that appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home.

[edit] What Brought Us Here?

In the 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine criticizes the fragmentation of health care requiring patients to jump through hoops and take responsibility for complicated medical information from one provider to the next.^[1] The Family Medicine community shortly thereafter identified what it sees as the fundamental flaws in the fragmented US health care system and set out to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. The result was The Future of Family Medicine: A Collaborative Project of the Family Medicine Community, which offered a series of solutions to integrate health care and improve the health of all Americans.

This Future of Family Medicine Project introduced the idea that every American should have a Personal Medical Home that serves as the focal point through which all individuals- regardless of age, sex, race, or socioeconomic status—receive their acute, chronic, and preventive medical care services. Through their medical home, patients can be assured of care this is not only accessible but also accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians.^[2]

Two trends are helping to build momentum around the medical home model: 1) a growing shortage of primary care clinicians due to adverse practice conditions; and 2) the increasing prevalence of chronic diseases among the U.S. population. It is important to note, however, that the medical home model is not without controversy. The disease management industry has successfully carved a niche between primary care practices and chronic care patients by calling attention to physicians’ lack of attention to patient coaching. Also, studies by RAND researchers and Dartmouth University have quantified the degrees of inaccuracy and misdiagnosis associated with chronic care patients treated in primary care settings. However, Vanderbilt studies and others confirm that patients prefer coaching by their primary care physician, even while acknowledging that most provide little follow-up support for self-management.^[3]

[edit] Why Is This Concept Important?

The US health care system currently performs at a level considerably below its potential: despite spending more on health care than any other nation, the United States does not have the best health care or the most effective health care system. Payers and patients alike are looking for better value in health care, desiring better quality of care for less cost^[4] A recent study estimated that if every American had a medical home, health care costs would likely decrease by 5.6 percent, resulting in national savings of $67 billion dollars per year, with an improvement in the quality of the health care provided.^[5]

Primary care is essential for the effective and efficient functioning of America’s health care delivery system. It is well established that having a regular source of care and continuous care with the same physician over time has been associated with better health outcomes and lower total costs^[6][7][8] We know that states with more primary care physicians show more efficient and effective use of care, leading to lower overall health care spending.^[9] It has also been demonstrated that among 18 wealthy Organization for Economic Co-operation and Development (OECD) countries a strong primary care system and practice characteristics such as geographic regulation, continuity, coordination, and community orientation were associated with improved population health. Data suggest that increased use of primary care physicians resulted in reduced hospitalizations and reduced spending for other non–primary-care specialist services with improvements in morbidity and mortality rates.

Most everyone agrees that the goal of health reform is personalized, coordinated, comprehensive care that is safe, affordable, and of high quality. Our current payment system encourages high volume, procedures, tests, and referrals. It does not reward the prevention of hospitalization, effective control of chronic conditions, or care coordination. This results in fragmented care leaving patients unhappy and primary care physicians demoralized. When we have unnecessarily high costs and reduced quality of care, access is at risk. Fundamental reform that provides comprehensive payment for comprehensive care is necessary.^[10]

Primary care physicians, on average, earn about $90,000 less than the average specialist.^[11] In part, this explains why fewer medical students choose primary care. Unfortunately, the current health care payment system values medical procedures more highly than health maintenance and disease prevention through patient collaboration. The Medical Home concept moves payment towards a greater emphasis on physicians and mid-level practitioners collaborating with patients to ensure health.

Most methods of collaboration central to the medical home, though, are not paid for under much of the current fee-for-service system, such as e-visit consultations and chronic disease management. This lack of relative value placed on efficient, patient-centered care discourages many physicians and mid-level practitioners from providing such services.

Under the Medical Home model practices would ensure the ability to handle same-day appointments and walk-ins. They would have Electronic prescribing connected to local pharmacies. Primary care offices will have interactive web sites moving patient self management to exciting new levels. The patient could access resources for preventative advice and chronic illness management, test results might be retrieved, medical records accessed, medication refills could be processed, office visits scheduled, surveys completed, and non-urgent questions could be sent to their personal physician through online communication.

In the medical home primary care is no longer a single physician craft but a complex set of tasks best managed by a multidisciplinary team. Since chronic illness management and lifestyle modification are central themes in the Medical Home, patients with similar problems could now be seen in groups led by physicians or other team members. The unique dynamics in group visits such as peer support could help with tackling tough problems such as obesity and diabetes.

Critical in the Medical Home is the adoption of electronic health records (EHR). The tracking of performance measures for quality reporting through chart reviews is inaccurate and costly. Through the technology afforded in EHR’s prospective data collection becomes a reality providing the physician with real-time quality measures for the purpose of benchmarking and improvement.

In the current system the average primary care physician cares for 1500-3000 people in a community and has approximately 5000 fifteen-minute visits a year. This allows about an hour per year per patient. That is not enough time to provide good preventative care, let alone treat illness. Needs for care do not end at an individual physicians door. A focal point of the Medical Home is that payment is not dependent on expensive and time consuming face-to-face visits. The Team approach with online care and group visits create efficiencies that should lower the cost of care for most patients while affording physicians more time to provide the quality care their patients and payers deserve.

[edit] How Is This Not a Gatekeeper Model?

Some suggest that the blended fee-for-service and partial capitation in this system mimics the “gatekeeper” models historically employed by managed care organizations. There are important distinctions between care coordination in the medical home and the “gatekeeper” model. 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. The Medical Home puts emphasis on medical management rewarding quality patient-centered care.

[edit] Is Anyone Already Doing This?

There are many demonstration projects across the country sponsored by multiple specialty organizations and state governments that are practicing and evaluating some or all of the Medical Home concepts. Below are four of the different types of projects underway, as of 2007.

• Division B, Section 204 of the Tax Relief and Health Care Act of 2006 outlines a Medical Home Medicare Demonstration Project. This three year project will involve care management reimbursement and incentive payments to physicians. It will evaluate the health and economic benefits of providing targeted, accessible, continuous, and coordinated, family-centered care to high need populations.^[12]

• TransforMED is a national demonstration project initiated and staffed by the American Academy of Family Physicians focusing on helping select physician practices redesign themselves following the Medical Home concept. This 24 month project initiated in June of 2006 is composed of 36 Family Medicine Practices of various sizes across the country. This project will provide an objective view into what this new model looks like in the real-world, and it will measure the model’s effect on practice and patient outcomes

• The National Committee for Quality Assurance (NCQA) has released Physician Practice Connection, which recognizes practices that use systematic processes and information technology. While recognition in the NCQA program will not qualify a provider as a Medical Home, physicians that change their processes and structures to pass recognition standards will be well on their way to accomplishing many of the principles desired in a Patient-Centered Medical Home.

• North Carolina’s Medicaid program shows excellent quality and cost outcomes after adopting several components of the Medical Home in their Community Care of North Carolina (CCNC) program. Through disease management payments, evidence-based clinical practice, and an emphasis on a physician-led team approach for case management they found significant improvements in cost, utilization, and quality measures. The program consists of an additional $5 per-member per-month case management fee, and an enhanced fee-for-service payment of 95 percent of the Medicare fee schedule for Medicaid covered services. Two major evaluations of this program has estimated that it has saved the state $195 to $215 million in 2003 and between $230 and $260 million in 2004.^[13]

[edit] See also

• Orphan patient

[edit] References

[edit] External links

• The Medical Home from American College of Physicians - HTML version

• Backer LA. The medical home: an idea whose time has come ... again. Fam Pract Manag. 2007 Sep;14(8):38-41. PMID 17912821

• Guadagnino C. Implementing a medical home. Physician's News Digest. 2007 Mar. [1] Accessed December 27, 2007

• Uncoordinated Care: A Survey of Physician and Patient Experience (California HealthCare Foundation, September 2007)

• The MedHome Portal About the medical home approach to care for children with special needs.