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.
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 room, people wouldn’t understand what to do,” Butcher says.
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,” Butcher says.
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.
Interviewed for this article: Kathleen Butcher, RN, CDDN, is a triage pediatrics nurse at Dartmouth-Hitchcock Clinic in Concord, N.H. (Kathleen.A.Butcher@Hitchcock.org)
Sidebar:
The Dartmouth-Hitchcock Medical Home Approach
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.