Hospitals and Patient Centered Medical Homes: A Practical Pairing

Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio.  Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.

The patient-centered medical home makes enormous sense, and it's a wonder the American healthcare landscape hasn't included this model all along. PCMHs are considered a fundamental component of healthcare reform, offering rich benefits to both providers and patients. While relatively new, the model is already showing considerable promise in the industry. According to the Patient-Centered Primary Care Collaborative, approximately 13 percent of primary care physicians currently practice in a PCMH. Still, as many as 70 percent of practices are either already in the process of becoming or interested in becoming a PCMH, according to a Medical Group Management Association survey.

In 1967, the American Academy of Pediatrics first introduced the idea of the "medical home" in the context of children with special needs. In its original form, the medical home brought together the services of specialists, primary care physicians, other clinicians and ancillary services to deliver coordinated and comprehensive acute, chronic and preventive care for children with conditions such as Down's syndrome. Over the next three decades, organizations such as the World Health Organization and the Institute of Medicine emphasized the need for medical care based on a primary care model. In 2007, the major primary care physician associations in the United States released the Joint Principles of the Patient-Centered Medical Home.   

Coordinated care, accountable care, preventive care — healthcare reform has unleashed a multitude of buzzwords commonly used to describe the same idea. PCMHs, however, are concrete. This model is a specific style of delivery for primary care practices, one that incorporates a team approach, enhanced accessibility and population management. In a PCMH, primary care physicians are part of a team of clinicians, often including health coaches, who engage patients as active participants in their own health. Hospitals and health systems pursuing accountable care need high-performing primary care practices as a foundation, and PCMHs can help hospitals and practices align incentives while delivering coordinated and comprehensive care.  

Mercy in Northwest Ohio is participating in a system-wide initiative with Catholic Health Partners to transform our primary care practices to PCMHs. In Toledo, we have included our family medicine residency in the initial group of practices on the PCMH transformation journey. In the residency setting, the focus of the PCMH remains not only on better patient care but also on the added dimension of training the next generation of physicians in this model of care that emphasizes care teams, data-driven quality improvement and patient-engagement.

Practices within a PCMH are high-performing in every sense of the word. They provide comprehensive primary care services for children, youth and adults, addressing their preventive, acute and chronic needs. These practices offer high-quality care and have strong financial performance. General internal medicine, general pediatrics and family medicine are the most common practices in a PCMH, however, some OB/GYN practices also consider themselves as primary care providers and may opt to transform into a PCMH.

The most common route for recognition as a PCMH is through the National Committee for Quality Assurance. Additionally, in July, the Joint Commission launched a Primary Care Medical Home option for JC-accredited ambulatory care organizations.

The Joint Principles established by the American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians and American Osteopathic Association include:

• Personal physician. Each patient has an ongoing relationship with a personal physician who is focused on continuous and comprehensive care as part of a care team.
• Physician leadership. Practices are physician-directed and have a team approach to care delivery. All members of the team, including physician assistants and nurse practitioners, are critical to the PCMH mission.
• Whole person orientation. The PCMH provides for all of the patient's healthcare needs or takes responsibility for appropriately arranging care with other specialists, clinicians and professionals.
• Care is coordinated and integrated. The PCMH works across the complex healthcare system and the patient’s community. Information technology plays an important role.
• Quality and safety. This includes evidence-based medicine, patients actively participating in decision-making and voluntary participation in quality measurements with a focus on active quality improvement. PCMHs rapidly adapt their policies, procedures and workflows based upon measured outcomes that are patient- and population-based.
• Enhanced accessibility. Access to care is available through open scheduling, expanded hours and expanded options for communication between patients and providers, such as patient portals and secure e-mail. .
• Payment. Fundamental to the PCMH is a recognition that the payment system must change to appropriately recognize the added value of this intense level of primary care. Increasingly, PCMH practices are paid for obtaining quality goals and providing care coordination and management services.

Population health management, a critical characteristic of the PCMH, is a process that most physicians — particularly those in the middle of their professional careers — may not have been trained to provide. Physicians have traditionally been taught to manage or care for one patient at a time. Now we're being asked to do more and to look at our entire population of patients. In the PCMH, physicians need to analyze their population of patients and discover what might be unique about them. In the NCQA recognition process, the PCMH is expected to focus on at least three chronic conditions and one at-risk group within the practice.

As a family physician, I spent the first half of my career in private practice in a suburban location. Now, I practice out of a residency program in the central city of Toledo. Diabetes is a prevalent condition in both locations, but there are different factors that I must recognize as a physician to better tailor my care.

In Toledo's central city, social-economic conditions are more commonly a barrier to care compared to my prior suburban practice population. In my suburban practice, alcoholism and addiction disorders were not uncommon. However, in my current practice population these conditions are more prevalent and often accompanied by abuse of controlled substances. Through population health management, physicians identify the key issues in their communities to better deliver the whole-person care so integral to PCMHs.

Hundreds of PCMH pilots across the country have revealed important trends, such as happier staff, happier physicians, improved practice revenue, increased take-home pay for physicians, a transition to team-based care and an increase in the standardization of care. On the patient side, PCMHs are linked to improved satisfaction, improved preventive care, reduced emergency department utilization, reduced hospital readmissions and reduced per capita cost for certain chronic conditions.

A recent study by Bertakis et al, published in the Journal of the American Board of Family Medicine, demonstrated an association of patient-centered care with an overall decrease in health care utilization measured by specialty care, diagnostic testing, hospitalizations and total charges. Although the study group was only 509 patients and the study period was only one year, the 34 percent lower total healthcare charges associated with the group of patients who received more patient-centered care is sure to attract attention of healthcare decision makers looking to "bend the cost curve."

For hospitals and health systems looking to improve the operations of their primary care practices, PCMH conversion may be the answer. In fact, many have turned to TransforMED, a wholly-owned subsidiary of the American Academy of Family Physicians, for guidance with the challenging process of PCMH transformation. Equally, if not more important, those hospitals and health systems planning their clinical integration strategies will likely find linkage to a network of PCMHs fundamental to success.

Related Articles on Patient-Centered Medical Homes:

MGMA: 70% of Practices at Least Interested in Becoming Patient-Centered Medical Home
Study: Patient-Centered Care Lowers Healthcare Costs
Regional Medical Center at Memphis and BlueCross Partner on Patient-Centered Medical Homes

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