Working in a Medical Home
Model: One Nurse’s Experience
by Lola Butcher
The medical home model relies on nurses who get to know
their patients well and plan and coordinate their care with the
goal of delivering the right care at the right time in the most
efficient way possible.
One pediatric nurse describes her experience in a medical home
pilot project.
Kathleen A. Butcher, RN, CDDN, a pediatric
triage nurse at Dartmouth-Hitchcock Clinic in
New Hampshire, likes to remember the family that
was able to go to Florida, courtesy of a medical
home project.
As a member of a medical home team during a
four-year grant-funded pilot, Butcher developed
care plans for children with special healthcare
needs. The mother of one of her patients had
been unwilling to travel for fear of a medical
emergency away from home.
Care Plans Take Center Stage
“Her child has a very rare diagnosis, and her
concern was that if they had to go to an
emergency department, people wouldn’t understand
what to do,” says Butcher.
The care plan describes the child’s medical
condition and provides instructions, for
example, on how to respond to certain laboratory
values and how to handle the child’s seizures.
“It gave that mother so much peace of mind to be
able to travel out of state and know that if she
walked into an emergency room, she had
everything she needed to tell the physicians,”
says Butcher.
Developing and implementing patient care plans
that proactively manage care delivery—including
preparing for possible emergencies—is an
important nursing function in the so-called
medical home. The care plan documents a
patient’s medical history and includes an action
plan for future care, such as laboratory tests,
imaging, medication refills, and check-ups,
complete with dates and identification of who is
responsible for making sure the activities are
completed.
What Is a Medical Home?
Care plans are only one element of the medical
home model, which seeks to put the patient,
instead of the physician, at the center of
healthcare delivery. Using electronic medical
records and nurse care managers, the model is
designed to keep an individual as healthy as
possible, instead of responding to sickness.
The medical home model seeks to transform care
by focusing on a patient’s total healthcare
needs in a proactive fashion. Physician
practices that demonstrate the capacity to
provide certain services—ranging from
evidence-based care to email contact with
patients—are designated as “medical homes.”
The theory of the patient-centered medical home
is that, if patients receive appropriate
outpatient care, their need for expensive
interventions and inpatient care will be
reduced. One example: if a cardiac patient takes
the appropriate medication and makes the right
lifestyle choices, he or she is likely to avoid
a heart attack or to need surgery. In that case,
a medical home nurse might develop a care plan
that calls for periodic weight checks and phone
calls to coach the patient to stick with the
medicine regimen, eat the proper foods and
exercise according to the plan.
What It Means For Nurses
While developing and overseeing care plans may
sound overwhelming, Butcher says it does not
increase a nurse’s workload. Rather, it involves
a different way of thinking.
“You’re trying to really address the whole
picture,” Butcher says. “For example, if you
have a parent that says, ‘My child is in a
wheelchair, and our dentist’s office is not
wheelchair-accessible,’ the easiest thing would
be to tell them to start calling numbers in the
phone book. But (in a medical home), the nurse
should know about the resources that meet that
need and how to connect that family with the
resources.”
That puts a nurse at the center of a patient’s
care, working with a multidisciplinary team that
operates proactively across the healthcare
continuum. In the pilot, Butcher served on a
team that included a pediatrician, a social
worker and two parents working together to
improve processes and ultimately patient
outcomes.
“It was invaluable to hear the different
viewpoints because we’re all coming from
different thought patterns,” she says.
Among the medical home initiatives she worked
on: developing communication devices for
non-verbal children, a parent forum in which
patients’ parents met to discuss the challenges
of caregiving, and a notebook of tips for
parents with special healthcare needs.
The concept of the patient-centered medical home
actually dates to 1967, when the American
Academy of Pediatrics (AAP) sought to improve
health care for children with special needs.
Over time, however, the AAP, the American
Academy of Family Practitioners and other
professional organizations have expanded the
concept to include all primary care.
Although Butcher works with children with
special healthcare needs, she believes all
patients would receive better care in a medical
home setting. “Regardless of a person’s health
status, it is really important to have a good
action plan as to which provider is doing what
and when,” she says.
Kathleen Butcher, RN, CDDN, is a triage
pediatrics nurse at Dartmouth-Hitchcock Clinic
in Concord, N.H.
(Kathleen.A.Butcher@Hitchcock.org)
Lola Butcher is a freelance writer and editor in
Missouri.
Sidebar
Leaders at the Dartmouth-Hitchcock Clinic are so
convinced the medical home model is the future of healthcare
delivery that they actively sought a private payer willing
to experiment with the medical home model. Earlier this
year, Cigna and Dartmouth-Hitchcock launched a medical home
pilot with about 19,000 Cigna members who receive care from
Dartmouth-Hitchcock’s 391 primary care physicians.
Here is how Cigna and Dartmouth-Hitchcock model is playing
out:
★ Patients are not assigned to a primary care physician; nor
do they actively choose one. Rather, patients are
“attributed” to a physician, on a retrospective basis, at
the end of the year based on where they have received the
preponderance of care.
★ The total cost of caring for the group of patients, after
risk adjustment, is compared to the total healthcare cost
incurred by a risk-adjusted comparison group. The difference
is the savings attributable to the medical home model. That
savings will be divided between the clinic, Cigna, and
self-funded employers whose benefits are administered by
Cigna.
★ Dartmouth-Hitchcock’s quality performance will be
determined by tracking how well the clinic adheres to
physician quality measures, established by the National
Committee for Quality Assurance (NCQA), as compared to a
similar group practice. Dartmouth-Hitchcock is eligible for
a bonus based on its quality performance from Cigna.
The program will be an ongoing initiative, as
Cigna intends to use it to gather data about the
effectiveness of the medical home model in
improving quality of care, improving patient
satisfaction, and reducing costs. The first
evaluation of the program will be made in late
2009.