Medical homes with the patient at the center

“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 termto 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 ofrelationship 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 theNational 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.

• Engage patients and families as stakeholders in developing and implementing medical home transformation initiatives, including the design of evaluation and the definition of outcomes.
• 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.
• 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.