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Medical Homes Work With The Patient At The Center



May 3rd, 2013
by David Keller

“Medical home” has become a term of art within the current wave of health reform.  It’s in the medical literature, on the internet and embedded in the Patient Protection and Affordable Care Act of 2010.

There is much debate over what “medical home” means and whether or not it works.  The Patient Centered Primary Care Collaborative published an overwhelmingly positive compilation of evidence last year supporting the concept.  At almost the same time, the Agency for Healthcare Research and Quality released a review of the literature that was much less positive, suggesting that the impact of practice transformation to the medical home is much less certain. So, in the end, what are we to believe when the messages are so mixed?

Given how the concept has evolved over time, it is not surprising that we are confused.  Historically, the term “Medical Home” comes from the American Academy of Pediatrics, which, in 1967, coined the term to describe a repository of records that would offset the dispersal of records between pediatric offices, health departments and hospitals.  Over the next 30 years, the concept developed into one of relationship between children, families and pediatricians.  Pediatric medical homes were primary care pediatric practices, partnering with families to serve children and youth with special health care needs, and emphasizing the need for care coordination within the many systems that serve the needs of children.

In this paradigm, the medical home is defined by a relationship; care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. To measure the medical home relationship, questions about the family’s relationship with a pediatric practice, focusing on these qualities of care, were developed and incorporated into national patient surveys such as the National Survey on Child Health.

Much research has shown that this medical home relationship is associated with better care and better outcomes at lower cost, the holy grail of health reform.  Therefore, creating more medical home practices as part of the ACA is a no brainer, right?

A Change In The Focus Of The Medical Home Concept

Not entirely.  Over the last 10 years, the medical home concept moved from the world of children with special health care needs to the world of adult medicine and chronic disease management.  In the process, a new definition of medical home was developed, one that focuses on the way in which the practice approaches care, rather than on the relationship of the patient to the practice.

The new definition, agreed to by the various primary care specialties in 2007, includes the identification of a personal physician in the context of a physician-directed medical practice, enhanced access to coordinated and/or integrated medical care with a whole person orientation, high standards of quality and safety, and payment that appropriately recognizes the added value provided to patients within the model.  While the original definition focused on what care should look like from the child and family’s perspective, the new model focuses on measuring the design and use of a system of practice to deliver care and how to measure the outcome of that care.

Indeed, the measures of “medical homeness” for this transformation, such as TransforMed’s MHIQ or the recognition standards developed by the NCQA originally had very little in them that reflected the patient experience.  As a consequence, often, all that the patient sees is more computers and doctors stymied by the changes in the practice.  While the change to a data-driven, outcome focused system seems the right thing to do, I often speak to patients in practices that are transforming who have no idea that their doctor is trying to become more patient centered.

Is this the change that we think will achieve the Triple Aim?  What if we totally change the structure of primary care practice to reflect the Joint Principles of the PCMH, and none of the patients notice?

In addition, the shift in the definition of the medical home from a patient perspective to a system perspective makes it difficult to assess the potential impact of PCMH on the health care system.  Are the lessons learned from the decades-long effort of the pediatric community relevant to the models of care that evolved after the release of the Joint Principles?  Studies that focus on changes in practice structure seem to show slow change in outcomes.  Studies that focus on the patient perception show that the medical home relationship is associated with better outcomes.

I think that the accumulated research suggests a logic model where the change in practice must lead to a change in the relationship between the patient and the practice in order to improve outcome overall.   Despite the mixed messages delivered by the different evaluations, both public and private payers have instituted changes in payment, supportive of training and measurement to drive change.  What do people think about that?  Is this the change we have been looking for?

Suggestions For Keeping The Patient At The Center Of The Medical Home

I worry that the medical profession has once again focused so much on technology that we have lost track of our relationship with the patient.  Any primary care provider will tell you that it is our long-term relationship with the patient that enables us to manage care without the heavy hand of rationing or gate-keeping.  Health information technology is a really useful tool, but it will not bring us to the promised land unless we use it to enhance our relationships with patient and families.  I would urge all involved in medical home transformation work to take practical steps to keep the patient at the center of the patient centered medical home.
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  1. Engage patients and families as stakeholders in developing and implementing medical home transformation initiatives, including the design of evaluation and the definition of outcomes.
  2. Measure the patient experience with the same vigor and rigor that you measure practice process and outcome and integrate those findings into your improvement processes.  The CAHPS-PCMH is a good start.  To paraphrase the mental health advocates, no PDSA cycles about us without us.
  3. Value all parts of the Triple Aim equally in choosing the path forward.  I know that we have problems with cost, but a narrow focus will not get us a long term solution to that problem.

We need to remember, amidst the obsession with cost and quality, that the development of a medical home relationship with our patients is at least as important as the technology and office systems that we deploy to meet the medical home standards.

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1 Trackback for “Medical Homes Work With The Patient At The Center”

  1. Medical Homes Work With The Patient At The Center – Health Affairs (blog) » Pediatric.me
    May 3rd, 2013 at 11:06 am

5 Responses to “Medical Homes Work With The Patient At The Center”

  1. stwilkins Says:

    Recent findings from published studies of PCMH pilots paint a very confusing picture in terms of outcomes. Some studies find moderate to significant improvements in HEDIS and other quality measures along with decreases in ER visits and hospital readmits…while other studies find no benefits at all.

    The explanation for these lack luster results can be tracked back to one of the concerns raised in Dr. Keller’s post:

    The focus of PCMH has been almost entirely on the build out of the HIT and staffing infrastructure needed to run a PCMH. Little if any attention in the PCMH build out has focused on the soft, inter-personal communication skills needed to transition care pare from the current paternalistic, physician-directed communication style to a patient-centered communication style. Health care is after all largely about high personal and emotional communications between people.

    Blake Anderson’s study is part of a long line of studies clearly linking strong, patient-centered provider communication skills to increased patient engagement, better outcomes, reduced ER visits and hospital readmits, better patient experiences. Unfortunately the same can not yet be said for EMRs, Registries, PHRs and patient portals.

    As a recent contributor to my blog wrote…”asking an EMR to engage a patient is like expecting a dictionary to tell a story. ” There not app for that.

    Steve Wilkins, MPH
    Mind the Gap
    http://www.healthecommunications.wordpress.com

  2. blakeandersen Says:

    Thanks to David and Paul for their excellent commentaries. While “patient centeredness” is the aim of the medical home because it is the right thing to do it is also the only way that the medical home will deliver expected value and fulfill the triple aims. Yet, patient-centeredness is not an aspiration, a hope or a motto, it entails a transformation in how we provide patient care, it requires a concrete skill-set. It requires a change from the acute to the chronic care, partnership model–since these are the patients that are the most frequently seen in primary care and drive 75% of health care costs. As we have seen over decades of implementing the Chronic Care Model, unless staff are prepared in a common platform of approaches for engaging these patients and facilitating disease self-care, adherence and lifestyle management, we will not be successful in impacting the 85% of avoidable health care costs due to behavioral, not medical factors. Our current health care workforce needs to be “retooled” according to the Institute of Medicine’s Health Professions Report, the World Health Organization’s Preparing the 21st Century Health Care Workforce and numerous studies showing the skill and proficiency of the health care team in chronic care and self-care support approaches is one of the single best predictors of patient level outcome in evaluations of the Chronic Care Model. Fortunately, we have highly successful approaches that have recently been shown in studies with Mercer, Fortune 100 companies and faculty of HealthSciences Institute to quadruple engagement rates. We have over 300 clinical trials showing that staff who are proficient in motivational interviewing health coaching deliver better patient-level outcomes. A recent study evaluated by health care evaluation expert Ariel Linden with Blue Cross Blue Shield of Michigan and HealthSciences Institute found proficiency in MI to be directly linked with a nurses success engaging a patient with a chronic disease http://www.bcbsm.com/content/microsites/blue-cross-blue-shield-of-michigan-news/en/index/news-releases/2012/june-2012/study-shows-blue-cross-blue-shield-of-michigan-health-care-nurse.html We need to use evidence-based medical care with evidence-based health coaching/self-care/decision-support. Yet, the MI skill-set is not easy to master, we do know how to train physicians and other members of the health care team to use it briefly and effectively–it can in fact be more efficient than the traditional advice and legacy patient education approaches (which numerous studies find so often fail and instead create discord for the highest risk patients). Let’s make the patient the center of the medical home and let’s use the best science and research from three decades from the fields of medical psychology, health psychology and motivational interviewing to do so. It’s the right way and the only way to deliver better patient-level results.

  3. hotelcattolica Says:

    This is great please preach it David Keller, great article! thank you

  4. Manisha Verma Says:

    Thanks to David Keller and Paul Grundy for posting this blog. I am very passionate about the “patient centeredness” of the medical home delivery model.

    Empowered patients as active navigators engaged in their own health can potentially improve the quality and safety of health care. They play a crucial role with their perceptive involvement and can act as “safety buffers” (Davis, 2012). Plans are to be prioritized and decisive steps needs to be taken to encourage active patient involvement and provide knowledge along with the support of their health care provider. The National Quality Forum (NQF) 2008 has ranked patient engagement as one of the top six priorities to improve quality and safety in the health care delivery system. Level of patient engagement is a significant predictor of cost and quality scores (Hibbard, 2013). However, true patient engagement is a challenging process.

    Carman et al. (2013) have provided a multidimensional framework for patient and family engagement at three levels: direct care (micro level), organizational design/ governance (meso level), policy making (macro level). At micro level, patients can be engaged in several ways, one of the example include informed shared decision making (Scholle, 2010), at meso level, they can be engaged as members of patient advisory council, and at macro level as members of board of directors.
    Some of the challenges to engage patients at different levels include:
    - Defining a segment of patient population willing to learn together either based on specific disease or demographic characteristics (Porter, 2013).
    - Identifying the correct methodology of engagement for different segments and making sure it aligns with the organization’s mission and values.
    - To keep newly defined population interested in social dialogue and encouraged to collaborate with their physicians as partners.
    - Rely on standard tools to measure the level of patient engagement. Measurement will allow in identifying the baseline scores, help design and evaluate interventions to shift the scores and may also serve as report cards for individual providers. PAM (Patient Activation Measure) is a robustly designed and validated instrument which quantifies the level of activation, and categorizes patients into 4 stages based on their responses (Hibbard, 2004).

    Patient engagement in healthcare is fundamental to decreasing healthcare expenditure, medical errors; promote quality, safety and overall better health outcomes. Investment in tools and interventions to enhance and measure patient-centric approach with high quality affordable care has gained attention in recent times. Several non-profit organizations like PCORI (Patient Centered Outcomes Research Institute) are investing in patient-centered outcomes research to improve methods and infrastructure for engaging patients at different levels. These research activities can further help with tracking and measuring quality and safety improvement initiatives and efforts in healthcare industry.

    Our aim during the health care delivery reform should be to achive E4 patients (Empowered, Engaged, Educated, and Enabled)

    References:

    1. Carman, K. L., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (2013). Patient and family engagement: A framework for understanding the elements and developing interventions and policies. Health Affairs, 32(2), 223-231.
    2. Davis, R. E., Sevdalis, N., Jacklin, R., & Vincent, C. A. (2012). An examination of opportunities for the active patient in improving patient safety. Journal of Patient Safety, 8(1), 36-43.
    3. Hibbard, J. H., Greene, J., & Overton, V. (2013). Patients with lower activation associated with higher costs; delivery systems should know their Patients’‘Scores’. Health Affairs, 32(2), 216-222
    4. Hibbard, J.H., Stockard, J., Mahoney, E.R., Tusler, M. (2004) Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Serv Res, 39(4):1005–1026.
    5. National Priorities Partnership. (2008). National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.
    6. Porter, M. E., Pabo, E. A., & Lee, T. H. (2013). Redesigning primary care: A strategic vision to improve value by organizing around patients’ needs. Health Affairs, 32(3), 516-525.
    7. Scholle, S. H., Torda, P., Peikes, D., Han, E., & Genevro, J. (2010). Engaging patients and families in the medical home. Agency for Healthcare Research and Quality, US Department of Health and Human Services.

  5. Paul Grundy Says:

    This is great please preach it David Keller — the foundation of medical home is a meaningful trusting healing relationship with the patient. “Any primary care provider will tell you that it is our long-term relationship with the patient that enables us to manage care” – the very core the foundation of care that will make a difference is a trusting healing relationship. As I read the early insightful work of one of my huge heroes Calvin Sia, MD, FAAP it became clear that kids with complex conditions need a place in the system that had a healing relationship of trust but where all the data was available in one place and a system held accountable to that data. From the stand point of buyers of care why would we not want that for all our patients all of our patients?

    So in 2006 we the large commercial buyers asked the house of primary care including pediatrics to give us agreed on principles and formed the http://www.pcpcc.net to drive that with primary care. On those principles we are trying to change the covenant away from episodes of care to be able to buy real relationship based PCMH level care just as Cal intended it to be when he first wrote about it. PCMH “a healthcare setting that facilitates partnerships between individual patients and their personal providers and, when appropriate, the patient’s family.” It lies at the center of the effort to address population health through provision of integrated and coordinated team-based care. It is a delivery organization that fosters clinician-led primary care with comprehensive, accessible, holistic, and evidence-based co-ordination and management. PCMH builds the infrastructure through which data flow and is held accountable as the system integrator. Study after countless study shows that when a patient has a primary care healer cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford. Our premise as a buyer is primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.

    While I would not argue that primary care should be all things to all people, it should be designed to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today. However, if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to get at any of the triple aim to control better quality ,better health or cost of care in the United States.

    I too would urge all involved in medical home transformation work to take practical steps to keep the patient at the center of the patient centered medical home.

    http://pediatrics.aappublications.org/content/113/Supplement_4/1473.long

    http://journals.lww.com/iycjournal/Abstract/2003/10000/Building_Medical_Homes_for_Children_With_Special.6.aspx

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