1.  The medical home: growing evidence to support a new approach to primary care

Author(s): Rosenthal TC

Source: J Am Board Fam Med 2008 Sep-Oct;21(5):427-40.

Summary: 

A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship between the patient and physician, formed to improve the patient's health across a continuum of referrals and services. Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction. The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit. Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes.

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2.  A medical home for children with insulin-dependent diabetes: comanagement by primary and subspecialty physicians--convergence and divergence of opinions

Author(s): Wegner SE, Lathren CR, Humble CG, Mayer ML, Feaganes J, Stiles AD

Source: Pediatrics 2008 Aug;122(2):e383-7.

Summary: 

The purpose of this work was to examine pediatricians' and endocrinologists' views about management for routine preventive and acute care, diabetes specific care, and family education and care coordination for children with insulin-dependent diabetes. Nearly all of the respondents agreed that primary care physicians should have responsibility for routine primary care. Likewise, large majorities favored endocrinologists as leads for diabetes specific care. However, large proportions of pediatricians and endocrinologists expressed differing opinions about the primary responsibility for family education and care coordination and for specific diabetes services. An effective medical home model of care depends on establishing clear lines of responsibility between the primary care physician and subspecialist. Approaches that recognize the appropriate division of care between primary care physicians and subspecialists, facilitate co-management when it is needed, and reward the collaboration required to provide medical homes for patients should be investigated as models of care.

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3.  Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices

Author(s): Friedberg MW, Safran DG, Coltin KL, Dresser M, Schneider EC

Source: J Gen Intern Med 2009 Feb;24(2):162-9.

Summary: 

The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied. This paper measures the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices. Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments.

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4.  Practice-based care coordination: a medical home essential

Author(s): McAllister JW, Presler E, Cooley WC

Source: Pediatrics 2007 Sep;120(3):e723-33.

Summary: 

Families who raise children and youth with special health care needs benefit from a team approach with care coordination across multiple services and settings. If primary care pediatricians, family physicians, and internists are to achieve optimal health care quality and improvement of existing health care delivery, care coordination will be an essential contributing process to their team approach. Several national health policy recommendations identify care coordination as a cross-cutting intervention to fill the gap between what exists and what is needed in health care today. A practice-based care-coordination (PBCC) model, including a definition and vision for care, a framework of structures and processes, and a position description with specific competencies, is needed. The improvement approach and model must be flexibly applied to have utility across diverse health care organizations. A medical home team approach, with fully developed PBCC services, will enhance health and cost outcomes for children, youth, and families and heighten the professional satisfaction of those delivering health care.

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5.  Medical home and transition planning for children and youth with special health care needs

Author(s): Burdo-Hartman WA, Patel DR

Source: Pediatr Clin North Am 2008 Dec;55(6):1287-97, vii-viii.

Summary: 

Although many physicians may practice medical home medicine, most of the health care system is set up for acute episodic care. For children and youth with special health care needs (CYSHCN), this is costly and inefficient care and unsatisfactory for the patient and family. Transition or the purposeful planned movement of adolescents and young adults with chronic conditions from child-centered to adult-centered care began to evolve in the 1980s as more and more CYSHCN survived into adulthood. There is some progress being made in the implementation of the medical home that may facilitate a more effective transition of young individuals who have developmental disabilities. The greatest barrier to successful transition remains ensuring affordable, continuous health insurance coverage for all young people with special health care needs throughout adolescence and adulthood and engaging adult-oriented health care systems to take over the medical care of these young individuals.

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6.  Measuring the medical home infrastructure in large medical groups

Author(s): Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B

Source: Health Aff 2008 Sep-Oct;27(5):1246-58.

Summary: 

The patient-centered medical home (PCMH) is a new model of comprehensive health care delivery, coordinated across the lifespan, and payment reform that emphasizes the central role of primary care. The PCMH model includes 7 components: a personal physician, physician-directed medical practice, whole-person orientation, coordinated/integrated care, quality and safety, improved access, and payment (recognizing the added value of participating in a PCMH). Although the medical home is widely discussed by policymakers, payers, and other stakeholders, the extent to which physician practices have the infrastructure in place to function as medical homes is not known. Using data from the 2006–07 National Study of Physician Organizations, we examine the extent of adoption of medical home infrastructure components among large primary care and multispecialty medical groups and their association with medical group size and ownership. Costs of implementation, prospects for widespread adoption, and gaps between the current and potential use of PCMH are deemed essential for the success of the PCMH model.

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7.  A review of the evidence for the medical home for children with special health care needs

Author(s): Homer CJ, Klatka K, Romm D, Kuhlthau K, Bloom S, Newacheck P, Van Cleave J, Perrin JM

Source: Pediatrics 2008 Oct;122(4):e922-37.

Summary: 

Medical home health care is increasingly touted for improved care for persons with chronic conditions, but the evidence has not been systematically assessed. This paper examined the evidence for the federal Maternal and Child Health Bureau recommendation that children with special health care needs receive ongoing comprehensive care within a medical home. We selected 33 articles that reported on 30 distinct studies, 10 of which were comparison-group studies. None of the studies examined the medical home in its entirety. Although tempered by weak designs, inconsistent definitions, and inconsistent outcome measures, the preponderance of evidence supported a positive relationship between the medical home and desired outcomes, such as better health status, timeliness of care, family centeredness, and improved family functioning. The evidence provides moderate support for the hypothesis that medical homes provide improved health-related outcomes for children with special health care needs. Additional studies with comparison groups encompassing all or most of the medical home attributes need to be undertaken.

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8.  A house is not a home: keeping patients at the center of practice redesign

Author(s): Berenson RA, Hammons T, Gans DN, Zuckerman S, Merrell K, Underwood WS, Williams AF

Source: Health Aff 2008 Sep-Oct;27(5):1219-30.

Summary: 

The patient-centered medical home (PCMH) is the newest idea being promoted as a transformative health system model of primary care. A PCMH combines a physician-directed practice with primary care physician (PCP) services. Based on a literature review and interviews with practicing physicians, we identify the main health system problems that the medical home has been promoted to address: deficiencies in patient-centered care, the challenges of chronic care, and relatively poor primary care compensation. Medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish—from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.

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9.  The problem of integrating behavioral health in the medical home and the questions it leads to

Author(s): Kessler R, Stafford D, Messier R

Source: J Clin Psychol Med Settings 2009 Mar;16(1):4-12.

Summary: 

Psychology and other behavioral health professions have amassed a broad empirical and clinical literature suggesting many medical presentations are best responded to with the addition of evidence based behavioral interventions. Despite this, psychology and behavioral health functions independently from medical practice and has not achieved a regular presence as part of medical practice. We suggest specific reasons for the current state of affairs including clinical, operational, societal labels, financial and training dimensions. Medical, psychological, administrative, and financial perspectives are reviewed. If the goals of health care system reform are to be reached, then a shift in the clinical conceptualization of care must happen; we must identify and challenge the current limitations of health care. This paper will identify the elements that need to be changed in order for psychology to be integrated into medicine rather than excluded from its policy, planning and operations.

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10.  Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home

Author(s): Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC

Source: Ann Fam Med 2009 May-Jun;7(3):254-60.

Summary: 

The patient-centered medical home (PCMH) is emerging as a potential catalyst for multiple health care reform efforts. Demonstration projects are beginning in nearly every state, with a broad base of support from employers, insurers, state and federal agencies, and professional organizations. A sense of urgency to show the feasibility of the PCMH is influencing the design and implementation of many demonstrations. In June 2006, the American Academy of Family Physicians launched the first National Demonstration Project (NDP) to test a model of the PCMH in a diverse national sample of 36 family practices. Early lessons from the real-time qualitative analysis of the NDP raise some serious concerns about the current direction of many of the proposed PCMH demonstration projects and point to some positive opportunities. We describe 6 early lessons from the NDP that address these concerns and then offer 4 recommendations for those assisting the transformation of primary care practices and 4 recommendations for individual practices attempting transformation.