Medical Home: The New Normal

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medical-home_1340894761.jpg - medical home

Patient-centered medical homes are revitalizing primary care and becoming the new normal, according to experts in the field. Change management on the practice side is crucial while payors slowly but surely begin the transformation away from the fee-for-service model.

Patient-centered medical homes (PCMHs) are becoming "the new normal," says Donald R. Lurye, MD, CEO of Elmhurst Clinic, which is based in the western suburbs of Chicago and incorporates 35 primary care physicians and more than 50 multispecialty providers. "We're past the pilot stage."

PCMHs are a local phenomenon in many ways, Lurye says. "The real issue isn't so much what you call it but what it does." For example, can providers easily access patients' information? Are services organized around patients? Is information added to the longitudinal record accessible to the next provider? To help achieve these goals, Elmhurst has appointed an ambulatory CMIO, as a practicing physician committed to leveraging technology to make care more accurate and efficient.

Making the transformation

Across the U.S., providers are well underway with their medical home programs. For example, Qualis Health, a Seattle-based nonprofit quality improvement organization, is leading a five-year initiative to support 50 safety-net clinics transform to the PCMH model. Begun in 2008, the initiative has led to a series of technical guides to show practices how to make the transformation.

"The most important thing a practice needs is leadership that understands what the vision of what a medical home really means," says Jeffrey Hummel, MD, MPH, medical director for clinical informatics. It means a different way of practicing medicine. "EHRs are a vital part of the infrastructure, but there's a lot more to it than just technology."

Other than the supportive leadership, practices need to establish a quality improvement environment and empanel each patient to a specific practice team, he says. "These are the foundational steps and if you skip them, it's hard to sustain a medical home." The quality improvement culture requires that people understand how to measure and evaluate the quality they're providing.

Good information systems are required but "are not sufficient to produce improved outcomes," Hummel says. "We need new ways of practicing that involve monitoring outcomes and the processes by which we achieve those outcomes. That's the way we'll be incented."

Targeting patients

Many PCMHs are designed around specific patient populations. "If anyone needs a medical home, the elderly do. Their care is so complex," says Charles E. Boult, MD, MPH, MBA, geriatrician and director of the Roger C. Lipitz Center for Integrated Health Care at Baltimore's Johns Hopkins Bloomberg School of Public Health, which created Guided Care, a PCMH for the elderly.

PCMHs have the potential to focus in on the approximate 5 percent of patients in the typical primary care practice who consume the greatest amount of healthcare resources, such as those older than 65 years with certain chronic conditions, complex needs and those who utilize healthcare at far greater rates than the rest of the patient base.

Guided Care is designed to coordinate patient care of multiple chronic conditions. Boult put into practice a registered nurse who focuses entirely on this high-risk population. After conducting an initial assessment, the nurse develops a care plan with the doctor, the patient and the patient's family. "The patient can enhance his or her engagement with the healthcare experience," he explains. That includes accurate medication adherence, managing physical activity, weight, blood pressure and nutrition, as well as coordinating with specialist appointments. The nurse checks on her patients monthly, monitoring them proactively. She coaches them to help with problems and sees them through hospitalizations.

"There's a big emphasis on reducing readmissions," Boult says. "Bounce-back" readmissions often are due to patients not understanding how and when to take their medications. The nurse helps with that and also knows what to look for to determine whether a condition is worsening. She asks patients if they have seen any other providers, had tests or taken medications so that all new information is incorporated into the overall plan.

One study assessing this care approach split approximately 900 patients into a control group and the Guided Care group. The Guided Care group's family caregivers were significantly less stressed and the physicians were significantly more satisfied working with the nurses and with the care they delivered, says Boult. He also oversaw a study on whether reductions in service utilization could be used to offset the cost of the nurse, and found a reduction in hospital readmissions and the use of skilled nursing facilities, as well as a 30 percent drop in home care.

Currently, the practice bears the cost of an approach like a specialized nurse "The challenge now is to work out a payment model by which insurers can provide funding for practices," Boult says. 

Primary care revitalization

The term medical home is being used to describe the revitalization of primary care, says David K. Nace, MD, chairman of the Patient-Centered Primary Care Collaborative, an industry/provider alliance looking to advance primary care and the PCMH. Various pilot programs produced their first-year results about two years ago and "the results have been phenomenally powerful in terms of reducing costs, increasing quality of care and increasing satisfaction—not only of patients but also care teams," he says.

Nace sees "a thousand candles burning" as people stop marginalizing primary care and start making it the center of healthcare. "How the ships leave the port varies in each community."

Establishing standards for information exchange is crucial, he says. Connectivity is key to "getting rid of all these stovepipes."

Timing also is important. "We need to get this going quickly, but if it's too quick, things could unravel. If we move too slowly, we won't achieve our goals within the time constraints of HITECH."

The Collaborative is working to help drive changes at the practice level as well. "We want to keep the ball moving on reforming practices. Health system transformation is hard work," says Nace. At the local level, payors need to change their reimbursement model. How to pay for primary care is a regional issue, he says.

The group also intends to keep a focus on patients and their families. "Engaging the patient is very difficult. It's such a different way of delivering care for both practices and the health system." The goal, Nace says, is patients connected to a single source of information and involved electronically in care planning and management.

The CMIO's role

Establishing a patient-centered source of data is critical, says Nace. "That's going to be a big challenge" and probably one that will fall to the CMIO. CMIOs also should consider access to data for both the patient and the practice team. Both parties need the same data, including medication list, problem list and care plan, to avoid the ongoing problem today: with no single source, data conflicts.

Meanwhile, meaningful use regulations continue to increase their focus on patient engagement. "Providers aren't used to thinking about how to get patients online," Nace says. The patient experience is yet another factor providers need to measure. "This is new for CMIOs to think about and it's an important role—how to measure and then leverage that information."

CMIOs also can help with change management, Nace says. "Change is really hard and it needs to occur at the local level." Healthcare organizations need to think about forging partnerships with other providers and with payors—which has "traditionally been a toxic relationship."

The CMIO's ability to bridge all the gaps will determine future outcomes, says Lurye. "The more CMIOs can make it easier for systems to exchange information quickly and accurately, while also providing friendly human-machine interfaces that will help the practicing physicians perceive value, the better the chances of success."