Advancing Innovation To Eliminate Health Disparities

Health Equity and the Patient-Centered Medical Home

The Institute of Medicine (IOM) set forth goals for care coordination in their report “Crossing the Quality Chasm: A New Health System For The 21st Century,” and established guidelines to address measuring disparities in access to and the quality of health care, and developing adequate data sources in the National Healthcare Disparities Report (NHDR).

The Patient Centered Medical Home (PCMH) is an approach that, along with better data capture and analysis, can be built using the IOM guidelines and utilized in high risk and underserved communities to improve health outcomes. A PCMH integrated care team model works more efficiently and effectively with forethought towards the complexities of contextual determinants and risk factors in populations with poorly managed chronic diseases or barriers to accessing care.

It’s a model that can be curative in that it can improve access to care, which accounts for only 15 to 20 percent of variation in morbidity and mortality, and attack quality of care concerns. It can also be preventive in that patients are engaged more directly for behavioral change. High risk chronic disease patients, like those with diabetes for example, often have daunting co-morbidities that overwhelm their understanding of how to appropriately seek the care they need. They also have varying non-medical needs that the provider isn’t aware of because they either don’t ask or the patient doesn’t voluntarily share such information.

Care Coordinating Entities (CCE) and Accountable Care Organizations (ACO) where PCMH is a featured model can bring together specialists, community service agencies, and care coordinators to initiate individualized care plans and outreach strategies in vulnerable populations. The strength of PCMH in CCEs and ACOs would be the use of health information platforms, electronic health records (EHRs), and non-physician personnel such as nutritionists and navigators (i.e. Community Health Workers/Promotores(as)).