The term medical home is used interchangeably with another term, Patient-Centered Medical Home to refer to a medical care approach which is gaining popularity with more people because it is cost-effective and ensures provision of high quality care. According to American College of Physicians, ‘A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes’. Even though the above definition is but one among many, all these definitions are guided by the same principles that ultimately enrich the concept of medical home. This model aims at attending to all the medical care needs of a patient. The personal physician works in collaboration with other health care professionals in order to deliver the highest level of care to their patients by enhancing access, communication, coordination, integration and quality. In other words, its objective is to provide a system of care. PCMH’s goal is not only to improve the quality and efficacy of medical care given to the patient, but also improve the satisfaction of both patient and the team of professionals.
History of Patient-Centered Medical Home (PCMH)
The term “medical home” was coined in by the American Academy of Pediatrics (AAP) in the year 1967 to refer to one source of medical information on a patient. With time, the use of this term was expanded to include activities that foster partnership between families and the medical care givers in order to provide primary health care to patients. The term’s use was extended even further in the year 2002 when the AAP reached a decision to increase 37 activities in the list of activities that make up medical home.
The principle by which medical home operates were founded at a 1978 conference by World Health Organization in Alma Ata. This meeting led to the Alma Ata declaration which pin pointed primary health care to be a basic human right. Also, it noted primary health care to be instrumental in attaining adequate health. The declaration further defined health not only as the absence of ailment, but the utmost well being physically, mentally and socially.
Family Medicine got a lot of influence from medical home in the 1990’s as a result of the Institute of Medicine (IOM), incorporating medical home principles in its reports. In 2002, family medicine embarked on a study to establish effective means of meeting patients’ needs and in the end recommended the medical home approach for every individual irrespective of their social or economic backgrounds.
Another development in the PCMH approach took place when the Chronic Care Model was incorporated. This model proved to not only be cost-effective, but to improve the quality of care accorded to patients suffering from chronic ailments. Later on in 2004, the America Academy of Family Physicians (AAFP) suggested this model be used in provision of primary care but stated that it needed alterations with regards to how the care can be paid for to ensure its sustainability.
To date, medical home comprises seven core features which have been unanimously affirmed by AAFP, AAP, ACP and AOA.
Components of Person-Centered Medical Home
This feature demands a patient be in constant contact with a physician who has received training in providing care in all of the following areas of care; first contact, continuous and comprehensive. Establishment of a relationship between patient and health care giver goes a long way in ensuring the patients’ well-being.
Physician directed medical practice
The personal physician of the patient takes the lead role in leading the rest of the professionals in the team into providing the best quality of care to the patient through combined responsibility.
Whole person orientation
The personal physician is solely charged with the responsibility of offering all the health care services that the patient requires. This includes but not limited to coordinating service provision by the rest of the professionals in the team during the different stages of offering, preventive, acute, chronic or end of life care.
Care is coordinated and/or integrated
In order to ensure that the patient obtains the care they need at the specified time and place and in the appropriate manner, facilitation is done through the use of information technology, health information exchange among others.
Quality and Safety
In order to ensure quality and safety throughout, the following are some of the practices included in the care provided.
- Both the patients and their families participate during the practice in order to improve on quality.
- The care givers make use of information technology in order to ensure best possible care for the patient, improve communication and measure performance.
- Decisions are made through use of evidence-based medicine and clinical decision-support tools.
Enhanced access to care
The access of medical home services are enhanced through activities such as creating of open schedules, more hours of operation and creation of a variety of communication strategies between the patient, their physician and other professional staff.
The structure of payment should be based upon certain principles aome of which are listed below.
- It should be able to realize the value of the input by all the staff involved in PCMH outside of the face-to-face contact between the patient and the health care givers.
- It should cover for the services provided by other collaborative participants such as consultants.
- In order to improve on quality, the payment structure should embrace the use of health information technology.
Issues in Patient-Centered Medical Home
There are certain intricate issues involved in the PCMH service provision. Even though it is acclaimed for its cost-effective aspect and its quality enhancing qualities, it has been marred by several disadvantages. First and foremost, the payment system is has major hindrances. Medicare, the largest purchaser of health care in the U.S., has payment policies that do not give recognition to the services offered by primary and principle health care practitioners. This has in turn had a negative impact in terms of the care given by the primary physicians who work in collaboration with other professionals.
The payments done by Medicare are founded upon the face-to-face encounters between the patient and physician hence the patient has to physically go to the physician’s office in order for him to get payment. In addition, the payment is based on the volume of work done. This however works against the physician because he takes a lot of time to establish the patient’s problems thus limiting his volume.
The current Medicare policies do not allow for payments to be made for numerous of the actions taken to coordinate the care services provided. Some of these include; telephone services, use of patient registries and the use of health information technology (HIT). The mentioned activities enhance patients’ access to medical home care, improve the quality of care as well as improve productivity of the physicians and other care providers.
Physicians, through their coordinated care, help in saving costs which could have been incurred by emergencies, hospital admissions and re-admissions and so forth. This is because they handle the patients who are at the highest level of risk. Unfortunately, the Medicare system which benefits greatly from the savings made does not have a mechanism that allows for the physicians to share in such benefits.
The sustainable growth rate formula is threatening to primary care practices. This, coupled with the high overhead costs which are fixed, Medicare payments which are below the rate of inflation and a limited volume of face-to-face visits by patients have devastating impacts on the viability of primary care practices such as PCMH.
Even with the numerous setbacks, PCMH has its advantages. This model allows for easy access of the care services by the patients. It does not include intermediaries thereby enhancing accessibility by those who need the service. There is also enhanced communication between the patient, the personal physician and all the other professional personnel involved in providing the health care. The patient gets to know his/her doctor together with the rest of the practitioners involved in their care. In addition to that, there is smooth coordination during care involving professional experts from different fields. The use of information technology goes a long way in enhancing efficacy through the use of disease registries and electronic medical records.
In conclusion, PCMH practice is a very effective strategy of providing high quality health care to patients. It however faces numerous policy issues in terms of payment that pose a great threat to its sustainable practice. The government through Congress however, can make it better by ensuring policy changes which are going to sustain the provision of primary health care.
American College of Physicians. (2009). What is the Patient-Centered Medical Home? Retrieved from http://www.medscape.com/viewarticle/589670
American College of Physicians. (n.d). Enhance Care coordination through the patient centered medical home (PCMH). Retrieved from http://www.acponline.org/running_practice/pcmh/understanding/pcmh_back.pdf
Cassidy, A. (2010). Health Policy Brief. Retrived from http://www.healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_25.pdfThe Patient Centered Medical Home. (2007). Retrieved fromhttp://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001 File.dat/PCMH.pdf
What is Medical Home? (n.d). Retrieved from http://www.cthealthpolicy.org/medicalhome/what_is_a_medical_home.pdf