The Medical Home Concept

Thursday, December 18, 2008

The Medical Home Concept (David Shippee) -- Health reform is again on the national agenda. States, foundations, the federal government, the health care industry, and the business community are all searching for ways to expand access, improve quality, and control health care costs. As we dissect, discuss, and debate the options to achieve these objectives, I encourage us to consider those alternatives that promote the development of medical homes.

The medical home concept originated with efforts by pediatricians to respond to the health, environmental, and social challenges faced by children with special health care needs. In recent years, health care professionals have recognized the value of identifying a medical home and providing coordinated care for adults as well, especially those with a chronic disease such as diabetes.

The medical home concept is based on a relationship between a patient and a primary care provider who serves as the patient’s first point of contact. The attributes of a medical home include:

Patient-centered care—where the patient actively participates in health care decisions that affect him
Accessible care—where the medical home provider is available nights and weekends to respond to patient concerns and avoid unnecessary emergency room use
Comprehensive, coordinated care—where the medical home provider proactively engages with other health care professionals and systems to share information and promote continuity of care. This coordination extends across all health care venues (e.g., hospital, nursing facility) and for all types of care (e.g., preventive, acute, chronic, end-of-life)
Culturally sensitive and linguistically appropriate care

These attributes are consistent with the six aims for improvement identified in the 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century—that health care should be safe, effective, patient-centered, timely, efficient, and equitable.

Transforming a medical practice into a medical home requires an investment in the infrastructure needed to support the responsibilities inherent in serving as a medical home. Providers need clinical-decision support tools that help to promote the practice of evidence-based medicine. Electronic health records and secure information technology are needed to support patient registries and the electronic exchange of health information between providers and with patients. These tools also support performance measurement which is critical to quality monitoring and improvement.

To achieve widespread adoption of the medical home concept, we will need to transform our payment systems to recognize the value of care management services to support medical home responsibilities. Such payment systems are not new. State Medicaid programs have long used primary care case management as a tool for promoting care coordination. Primary care providers receive an enhanced payment each month in return for agreeing to coordinate a patient’s medical care.

Although investing in infrastructure and providing enhanced payments cost money, the benefits of promoting medical homes on a national scale will be worth it. A 2006 Commonwealth Fund survey revealed that adults who had medical homes experienced both better access to care and better quality care. The survey results also suggested that racial and ethnic differences in access to care, and quality of care, are both reduced when minorities have insurance coverage and a medical home.

A number of organizations support the advancement of the medical home model. As noted above, the Commonwealth Fund is engaged in several research initiatives to evaluate the effectiveness of medical homes at reducing costs and improving quality. The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association endorsed a set of joint principles of a patient-centered medical home in 2007. The National Committee for Quality Assurance (NCQA), the accreditation body for health plans in the U.S., has developed a set of standards and guidelines based on those joint principles that serve as the basis for physician practices to be recognized as patient-centered medical homes. The Healthy Howard program that launches in several weeks in Howard County will adopt this very concept as it partners health coaches, employed by the program, with primary care providers at Chase Brexton Health Services using the features mentioned above to care for the enrollees in the program. And the adage fits here as well…there is no place like home.