The Patient-Centered Medical Home (PCMH):

Building a Better Health Care Model

Objectives

• Identify current priorities for health reform.• Describe the Patient-Centered Medical

Home (PCMH) model of care.• Understand how the PCMH model is an

appropriate vehicle to address priority health reform issues.

• Understand Family Medicine’s role in the development and adoption of the Patient-Centered Medical Home.

Patients today are savvy consumers of health care and have

higher expectations. – Communication– Access– Convenience– Coordination– Responsiveness

• Source: Medfusion, an AAFP affinity partner, 2008

Patient Expectations

• 75% want the ability to interact with their physician online (appointments, prescriptions, test results).

• 77% want to ask questions without a visit.• 75% want email access as part of their overall

care.• 62% of patients say access to these services

would influence their choice of physicians.

– Source: Medfusion, an AAFP affinity partner, 2008

Family Medicine is leading the way to make health care more patient-centered.

“Will family medicine teachers prepare their students and residents to help practices transform and meet the infrastructure principles? I believe that we will, not simply because doing so will likely increase our financial situation but because building PCMHs that meet the care and infrastructure principles will improve the care we provide to meet our patients’ and our communities’ needs. We will build our PCMH practices, because it is the right thing to do and it reflects our core values.”

John C. Rogers, MD, MPH, MEdPast-President,Society of Teachers of Family MedicineFam Med 2008;40(1):11-2.)

Health Care Reform

Priorities for US health care reform include: • Quality

– WHO (World Health Organization) identifies the US health care system as the “most individually responsive”

– WHO ranks US health care 37th overall (among 191 countries) • Efficiency

– People with acute and chronic medical conditions receive only about two-thirds of the health care that they need.

– Between 20 and 30% of tests and procedures provided to patients are neither needed nor beneficial.

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth Fund *Schuster, McGlynn, and Brook, 1998

Health Care Reform

Priorities for US health care reform include: • Cost

– The U.S. spends more on health care per capita than any other nation.

– The U.S. spends more on health care as a proportion of GDP (Gross Domestic Product) than any other nation.

• Patient-friendly– Public confidence in hospitals and personal doctors remains

relatively high. – While individuals report generally positive experience with

medical care, public confidence and trust in the system at large is eroding.

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth Fund

Health Care ReformPriorities for US health care reform include:• Access

– Lack of insurance is a major reason for not obtaining access to needed care.

– The 40 million Americans without insurance coverage are less likely to obtain needed medical care and preventive tests

– Even with insurance, barriers to care still exist:• Lack of an established relationship with a doctor• Language barriers• Cultural barriers• Transportation issues• Geography

• Automation– Infrastructure for health care delivery has not kept pace with the

electronic innovations of other industries.– Many institutions still rely on systems that are not automated and allow

opportunities for human error, even though technology exists to minimize errors and improve efficiency.

An effective and efficient health care system is a primary care-

based health care system– Provides access to basic health care services– Manages health disparities– Coordinates care– Controls cost – Offers sustainability

• www.aafp.org/valueoffamilymedicine

Innovative Solution:History of the PCMH Concept

• Introduced by American Academy of Pediatrics (AAP) in 1967• Initially referred to a central location for medical records • The medical home concept was expanded in 2002 to include:

– Accessible– Continuous– Comprehensive– Family-centered– Coordinated– Compassionate– Culturally sensitive care

• In 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA), and the American College of Physicians (ACP) adopted a set of joint principles to describe a new level of primary care.

“Joint Principles” of the Patient-Centered Medical Home

• A personal physician who coordinates all care for patients and leads the team.

• Physician-directed medical practice – a coordinated team of professionals who work together to care for patients.

• Whole person orientation – this approach is key to providing comprehensive care.

• Coordinated care that incorporates all components of the complex health care system.

• Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met.

• Enhanced access to care – such as through open-access scheduling and communication mechanisms.

• Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.

Growing Support for the Patient- Centered Medical Home

• Partnerships are developing as more and more stakeholders see value in the Joint Principles.

• The Patient Centered Primary Care Collaborative (PCPCC) is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others to develop and advance PCMH.

• The PCPCC has well over 500 members.

*www.pcpcc.net

Patient-centered | Physician-directed

The Patient Centered Medical HomeThe Family Medicine Model

Family Medicine Foundation

Health IT

Patient Experience

Health IT

Great Outcomes

Practice Organization

Quality Measures

Heath Information Technology

PatientExperience

Performance Measurement

Culture of Improvement

Reliable Systems

• Quality measures should be based in strong clinical evidence • You can’t improve what you don’t measure

• Starts with a culture of improvement • Ensure quality improvement initiatives are not punitive; should not discourage physicians from caring for patients

• Develop reliable systems to collect information

Quality Measures

Personalized CareConvenient Access Care Coordination

• Patients want convenient access to information, communication, and care• Patients want to access to care when they are ill

• Patients are engaged in their own care and want to share in decision-making • Patients want increased ability to access information

• Patients want coordinated care• Patients want new approaches to care: group visits and on-line services

Patient Experience

Quality Measures

• Lab testing• Prescriptions• Registries

Practice Organization

Personnel Management Clinical Systems

• Every team member understands the important role they play in delivering efficient care and is empowered to make suggestions for improvement

• Lab testing• Prescriptions• Patient Registries

Financial Management

• All staff are aware of the most effective ways to deliver care• National policies support the investment of resources into primary care practices that are effective and efficient

Quality Measures

PatientExperience

Business & Clinical

Process Automation

Family Medicine Foundation

Connectivity &

Communication

Evidence-Based

Medicine Support

Clinical Data Analysis

& Representation• Patient reminders• Patient notification for new information • Reminders for recommended care or health maintenance• Makes patient registries possible

• Can quickly pull clinical data for quality analysis• Can enhance business processes

• Enhances care coordination by improving information flow with other physicians, practices, and providers• Improves patient - physician communication

• Point-of-care learning (e.g., Up-to-Date)• Clinical decision support (e.g., Epocrates)

Practice Organization

Quality Measures

Patient Experience

Health Information Technology

Family Medicine Foundation

Great Outcomes• Good for patients

– Patients enjoy better health.– Patients share in health care decisions.

• Good for physicians– Physicians focus on delivering excellent

medical care.

• Good for practices– Team works effectively together.– Resources support the delivery of

excellent patient care.

• Good for payors and employers– Ensures quality and efficiency.– Avoids unnecessary costs.

Great Outcomes

Practice Organization

Quality Measures

Patient Experience

Health Information Technology

Patient-centered | Physician-directed

The Patient Centered Medical HomeThe Family Medicine Model

Family Medicine Foundation

Health IT

Patient Experience

Health IT

Great Outcomes

Practice Organization

Quality Measures

Heath Information Technology

PatientExperience

The PCMH Model in Action:North Carolina Community Care Collaborative

• Asthma and diabetes initiatives were developed due to high prevalence in the North Carolina Medicaid population.

• Care was coordinated by a primary care physician.• Care included patient education and team collaboration. • Initial goals focused on reducing unnecessary hospital

admissions and emergency room visits. Additional quality, efficiency, and cost control elements were added later.

• The CCNC Asthma Program demonstrated cost-effectiveness. – 34% lower hospital admission rate.– 8% lower ED visit rate.– Average ED “episode” cost for children was 24% lower. – 21% increase in asthma patients who have been staged. – 112% increase in asthmatic patients receiving flu shots. – $3.5 million dollar savings

The PCMH Model in Action:North Carolina Community Care Collaborative

• The CCNC diabetes initiative demonstrated improvement in process measures and implementation of evidence-based best practice guidelines. – 7% increase in referrals for dilated eye exams.– 23% increase in bi-annual foot exams. – $2.1 million savings.

• Without any concerted efforts to control costs, the program overall saved $60 million in 2003, $124 million in 2004, and $231 million in 2005 and 2006.

• Almost $1 M in savings achieved during the first two quarters of 2005 just for prescription use.

• www.communitycarenc.org

The PCMH Model in Family Medicine Residency Training

• “Preparing the Personal Physician for Practice” (P4)• The P4 Initiative is designed to inspire and examine innovation in family

medicine residency training.   • Sponsors are the American Board of Family Medicine, the Association of

Family Medicine Residency Directors, and TransforMED.• Different approaches range from moving the continuity clinic into a new

community setting, to expanding to a four-year program, to providing the opportunity for tracking and obtaining additional degrees while in training, and more. 

• The aim of P4 is to spur innovation in all family medicine residencies to best prepare family physicians be the excellent personal physicians of tomorrow.

• Initially, 84 Family Medicine residencies applied to participate in the P4 Initiative.

• The 14 P4 residencies were selected as participants for more intensive evaluation of outcomes to determine what works best.

• Findings are being shared with all residencies to inspire more innovations and change.

• http://transformed.com/p4.cfm

PCMH Model and Health Care Reform

• Attempts to fix part of the problem without addressing it comprehensively will not lead to viable solutions.

• Advocacy by all stakeholders is necessary.– Community projects through local hospitals and

resource networks– State projects for regional payors and state Medicaid

programs– National support for changing how care is delivered

and for ensuring a prepared workforce to deliver care

Family Physicians and the PCMH

• PCMH is a place, not a person.• Patient-centered, Physician-directed.• Family physicians

– Provide comprehensive care– Care for all patients– Coordinate care– Provide care that is effective

and efficient*

• Future of Family Medicine• *Starfield data

Great Outcomes

Practice Organization

Quality Measures

Patient Experience

Health Information Technology

Family PhysiciansHow we provide care:

• Acute injuries and illnesses• Health promotion and behavior change• Hospital care• Chronic disease management• Maternity care• Well-child care and child development• Primary mental health care • Supportive and end-of-life care

Family PhysiciansHow we view patients:

• Consider all of the influences on a person’s health.

• Know and understand people’s limitations, problems, and personal beliefs when deciding on a treatment.

• Are appropriate and efficient in proposing therapies and interventions.

• Develop rewarding relationships with patients.• Provide a continuous healing relationship over

time.

• Individuals and families

• Women and men regardless of age or disease

• Infants, children, and adolescents regardless of disease

• Communities and public health

• Global health

Family PhysiciansWho we care for:

Primary Care Delivers Better Health Outcomes

mortality

morbidity

medication use

per capita expenditures

patient satisfaction

greater equity in health care

SOURCE: B. Starfield, et al., “The Effects of Specialist Supply on Populations’ Health,” Health Affairs (March 2005); W5-97

The Patient-Centered Medical Home as a Preferred Model of Care

• Change is coming:– Patients want more from the healthcare

system and from their physician.– Purchasers of insurance (individuals,

employers, government) are looking for quality and value.

– Runaway healthcare costs must be addressed in ways that preserve and enhance access to high-quality, effective medical care.

– There are ways to do both!

Explore Family Medicine• Learn more about PCMH. (www.aafp.org/pcmh)

• Advocate for your patients.

• Think about the future of healthcare. Are you learning the skills today that you will need for the changing healthcare system?

• Visit Virtual FMIG. (www.fmignet.aafp.org)

• Join your local FMIG.

• Join the AAFP. (www.aafp.org)

• Get involved at the state and national level.