In pilot and demonstration projects around the country, the patient-centered medical home is being tested as a possible remedy for poorly coordinated care that wastes money and harms patients. The medical home model seeks to transform care by focusing on a patient’s total healthcare needs in a proactive fashion. The business theory: If patients receive appropriate outpatient care, their need for expensive interventions and inpatient care will be reduced.
Exhibit 1
What Is a Medical Home?
While the details of a medical home differ from one pilot project to the next, all emphasize the importance of primary care. The September/October 2008 issue of Health Affairs identifies seven essential components for a medical home:
- An ongoing relationship between a patient and a personal physician
- Physician-directed medical practice, in which a team of people share responsibility for patients’ ongoing care
- Whole-person orientation, meaning that the personal physician provides all of a patient’s healthcare services or coordinates care—including acute and chronic care, preventive services, and end-of-life care—to be delivered by other professionals
- Care that is coordinated and integrated throughout the healthcare system and the patient’s community; such coordination requires patient registries, health information exchange, and other things
- Use of evidence-based decision support, active engagement in quality improvement activities, and other strategies to delivery high-quality care that ensures a patient’s safety
- Timely access to care and better methods of communication, such as telephone and email contacts, between patients and professional caregivers
- Payment that recognizes the added value of care provided through a medical home
Source: Rittenhouse, D. et al, “Measuring the Medical Home Infrastructure in Large Medical Groups,” Health Affairs, Sep./Oct. 2008, vol. 27, no. 5, pp. 1246-1258.
Exhibit 2:
A Sample of Medical Home Pilot Projects
- The Centers for Medicare and Medicaid Services (CMS) is currently in the midst of selecting physician practices to participate in a medical home demonstration project that will begin in 2010. The project will be conducted in up to eight states and involve about 400 medical practices. (For more details, visit www.cmsmedicalhome.com.)
- In 2008, Dartmouth-Hitchcock Clinic and Cigna launched a medical home pilot with about 19,000 Cigna members who receive care from Dartmouth-Hitchcock’s 391 primary care physicians.
- In 2008, Group Health and Health Insurance Plan of New York—two leading insurers in New York—announced a two-year medical home pilot involving about 20,000 patients.
- UnitedHealth Group is conducting a medical home pilot program in Florida in conjunction with the American Academy of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association, and the American College of Physicians.
- HealthPartners, a large Minnesota-based plan that is integrated with a health system, expects to start a medical home pilot in 2009.
Exhibit 3:
What It Means for Hospitals
The primary way that a medical home concept saves money is keeping patients with chronic diseases out of the hospital. For hospital providers, the evolution toward medical homes means there may be fewer acute care patients; but the ones who are admitted are likely to be sicker and more expensive to treat.
“The hospital has the opportunity to have sicker patients and more flow through than you would if you are readmitting patients because their underlying disease state is not in good control,” says Barbara Walters, MD, senior medical director, of the New Hampshire-based Dartmouth-Hitchcock Clinic, which is integrated with Mary Hitchcock Memorial Hospital. “You’ll be able to have your beds filled by the sicker and more complicated patients, and you’ll keep your revenue stream flowing that way.”
For hospitals that employ primary care physicians, Walters offers the following advice.
Jump on board the medical home train. Educate your physicians about how the medical home model works and start developing the necessary infrastructure required for the medical home to succeed, ranging from electronic medical records to nurses who serve as health coaches.
Work to receive medical-home recognition from the NCQA. “That appears as if it’s going to be the price of entry into the model,” says Walters. Since 2008, NCQA has been assessing medical practices that wish to serve as medical homes. To be recognized, a practice must demonstrate its ability to meet criteria under nine standards, such as care coordination and performance reporting.
Start studying the billing issues. In a medical-home arrangement, physician groups get paid for services—such as creating care plans—that do not involve face time with a patient. “A lot of the things that you bill for trigger an explanation of benefits and copayments,” says Walter. “Patients would have no idea why they were getting billed for work that a nurse in the background did to create care plans for them,” says Walters. “It’s very challenging to figure out the way to not trigger that.”
Hospitals that do not employ primary care physicians should be staying on top of medical home projects in their community. “This can change the case mix or the hospital services that they will provide, given what their physicians are doing in their catchment area,” says Walters.
Exhibit 4:
What It Means For Nurses
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.
Take the medical home experience at Dartmouth-Hitchcock Clinic in Concord, N.H. The clinic reorganized its work so that patient care is provided proactively, rather than only when a patient calls for an appointment. Nurses develop care plans for patients with chronic conditions and serve as health coaches, making sure patients understand how to comply with physician orders. Nurses also track patients with chronic conditions via “registries” that show a patient’s health status and appointment history. “We know who our diabetics are and know what all of their key indicators are so we know who has good control, bad control, who has been seen, and who hasn’t been seen,” says Barbara Walters, MD, the clinic’s senior medical director.
Another key change is preparing patients for a meaningful session with the physician. “We call them to say, ‘We noticed you haven’t been in here. I want you to get all these lab tests and come in to talk about your diabetes. Let’s set up an appointment,’” says Walters. “The patient shows up with lab values in hand, and the physician gets a patient who understands his or her disease and is prepared to discuss how to manage it.”
However, it does involve a different way of thinking. “You’re trying to really address the whole picture,” says Kathleen A. Butcher, RN, CDDN, a pediatric triage nurse at Dartmouth-Hitchcock “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. However, in a medical home, the nurse should know how to connect that family with appropriate resources.”
That puts a nurse at the center of a patient’s care, working proactively with a multidisciplinary team that crosses the healthcare continuum.