THE MEDICAL HOME' : An Evolving American Strategy to


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THE MEDICAL HOME' : An Evolving American Strategy to

  1. 1. THE ‘MEDICAL HOME’ : An Evolving American Strategy to Provide Comprehensive Primary Health Care to Vulnerable Patient Populations The Future of Primary Health Care in Europe (II) European Forum for Primary Care (EFPC) University of Southampton, England Monday, 15 th September 2008 Dennis L. Kodner, PhD, Professor of Medicine & Gerontology and Director, NYIT Center for Gerontology & Geriatrics and Jamie Yedowitz,BS, OMS III, New York College of Osteopathic Medicine of New York Institute of Technology (NYIT), Old Westbury, New York 11568-8000, USA — Contact: [email_address]
  2. 2. PRIMARY CARE INNOVATION & REFORM: THE AMERICAN CONTEXT <ul><li>There are a number of developments and trends in the U.S. health system </li></ul><ul><li>that are driving interest on the policy and practice levels in primary health </li></ul><ul><li>care innovation and reform—including the ‘Medical Home’ approach: </li></ul><ul><ul><li>Overemphasis on specialization and specialty referrals; </li></ul></ul><ul><ul><li>Growing shortage of primary care physicians due to </li></ul></ul><ul><ul><li>adverse practice conditions, i.e., status, low pay, </li></ul></ul><ul><ul><li>and overwork; </li></ul></ul><ul><ul><li>Population aging and increasing prevalence of chronic </li></ul></ul><ul><ul><li>diseases; </li></ul></ul><ul><ul><li>Focus on episodic care; </li></ul></ul>
  3. 3. THE AMERICAN CONTEXT ( cont’d ) <ul><ul><li>Coordination and continuity of care problems—especially </li></ul></ul><ul><ul><li>for patients with complex conditions and multiple needs; </li></ul></ul><ul><ul><li>Poor value for money—despite world’s costliest system; and, </li></ul></ul><ul><ul><li>Archaic FFS payment methods that do not promote </li></ul></ul><ul><ul><li>quality or efficiency. </li></ul></ul>
  4. 4. THE INTEGRATION CHALLENGE IN PRIMARY HEALTH CARE <ul><li>Integration or coordination of care—initiatives at the micro, meso and </li></ul><ul><li>macro levels to enable different parts of the health system to work more </li></ul><ul><li>effectively and efficiently together—is a major driver of concern about </li></ul><ul><li>contemporary healthcare’s ability to address the needs of ever- </li></ul><ul><li>increasing numbers of people for more complex, comprehensive, and </li></ul><ul><li>continuous care. To strengthen primary health care’s pivotal role in the </li></ul><ul><li>care enterprise, new and innovative concepts must be melded to: </li></ul><ul><ul><li>Operationalize a holistic understanding of health and </li></ul></ul><ul><ul><li>its multiple determinants; </li></ul></ul><ul><ul><li>Emphasize health promotion/prevention and </li></ul></ul><ul><ul><li>rehabilitation—in addition to illness treatment; </li></ul></ul><ul><ul><li>Enhance multi-disciplinary team care and collaboration </li></ul></ul><ul><ul><li>across time and service setting; </li></ul></ul>
  5. 5. THE INTEGRATION CHALLENGE IN PRIMARY HEALTH CARE ( cont’d ) <ul><ul><li>Assure accessibility to needed care/services; </li></ul></ul><ul><ul><li>Engage and support patients/families as care </li></ul></ul><ul><ul><li>partners; and, </li></ul></ul><ul><ul><li>Facilitate evidence-based clinical management: </li></ul></ul><ul><ul><li>“ one-to-one” and “one-to-n”. </li></ul></ul><ul><ul><li>Sources : Powell Davies, 2006; Kodner & Spreeuwenberg, 2002; Wagner, 2000; </li></ul></ul><ul><ul><li>Barnes, 1997; Greenlick, 1992 </li></ul></ul>
  6. 6. THE ‘MEDICAL HOME’: A GENERIC DEFINITION OF THE MODEL <ul><li>The ‘Medical Home’ is not a place, but rather an approach to providing </li></ul><ul><li>comprehensive, patient-centered primary health care. The Primary Care </li></ul><ul><li>Physician (PCP) works in partnership with the patient/family to assure that </li></ul><ul><li>their medical and health-related needs are met through accessible, </li></ul><ul><li>coordinated, culturally-sensitive care delivered on a continuous basis and </li></ul><ul><li>across all disciplines, settings and services in order to achieve optimum </li></ul><ul><li>health outcomes and quality of life. To use the terminology of Geoff </li></ul><ul><li>Meads, the model is part “Extended General Practice”/part “Managed Care </li></ul><ul><li>Enterprise”. Essential elements include: </li></ul><ul><ul><li>PCP with back-up from physician-directed practice staff </li></ul></ul><ul><ul><li>capable of providing/arranging/monitoring comprehensive </li></ul></ul><ul><ul><li>services and managing population-based health outcomes; </li></ul></ul><ul><ul><li>“ Whole person” orientation focusing on all of the patient‘s </li></ul></ul><ul><ul><li>medical/health needs and incorporating holistic methods </li></ul></ul><ul><ul><li>with conventional allopathic interventions; </li></ul></ul><ul><ul><li>Incorporates Wagner’s Chronic Care Model; </li></ul></ul>
  7. 7. THE ‘MEDICAL HOME’: A GENERIC DEFINITION OF THE MODEL (cont’d) <ul><ul><li>Emphasis on preventive and self-care measures, including </li></ul></ul><ul><ul><li>health coaching, behavior modification, etc. </li></ul></ul><ul><ul><li>Electronic Medical Record (EMR); </li></ul></ul><ul><ul><li>Care management—vertically and horizontally—to arrange </li></ul></ul><ul><ul><li>and coordinate all of the patient’s medical/health care </li></ul></ul><ul><ul><li>services, as well as monitor changing personal health status </li></ul></ul><ul><ul><li>and needs on a longitudinal basis; </li></ul></ul><ul><ul><li>Evidence-based clinical decision-making; </li></ul></ul><ul><ul><li>Care anywhere, any time, e.g., via open scheduling, </li></ul></ul><ul><ul><li>expanded hours, group visits, telephone/email consultation </li></ul></ul><ul><ul><li>and other innovative communications options, cyber-visiting, </li></ul></ul><ul><ul><li>customized educational tools, and self-monitoring devices; </li></ul></ul>
  8. 8. THE ‘MEDICAL HOME’: A GENERIC DEFINITION OF THE MODEL (cont’d) <ul><ul><li>Technology and clinical information systems to facilitate </li></ul></ul><ul><ul><li>patient communication/monitoring, high-quality care, </li></ul></ul><ul><ul><li>practice based-learning, patient education, and quality improvement; </li></ul></ul><ul><ul><li>Ongoing patient engagement and feedback, and </li></ul></ul><ul><ul><li>informed, activated patients; </li></ul></ul><ul><ul><li>Accountability for performance/outcomes; and, </li></ul></ul><ul><ul><li>Supportive payor coverage policies, financing, and </li></ul></ul><ul><ul><li>reimbursement methods/incentives. </li></ul></ul><ul><ul><li>Sources : Robert Graham Center, 2007; American College of Physicians, 2006,2004; </li></ul></ul><ul><ul><li>Meads, 2006; Davis, Schoenbaum & Audet, 2005; Bodenheimer, Wagner & Grumbach, </li></ul></ul><ul><ul><li>2002; Medical Home Initiatives for Children with Special Needs Project Advisory </li></ul></ul><ul><ul><li>Committee,2002; American Academy of Pediatrics Ad Hoc Task Force on Definition of the </li></ul></ul><ul><ul><li>Medical Home, 2002: Wagner, 1998; Austin & Van Korff, 1996; Institute of Medicine, </li></ul></ul><ul><ul><li>1996; Deloitte Center for Health Solutions, n.d. </li></ul></ul>
  9. 9. IN THE BEGINNING: MEDICAL HOMES FOR CHILDREN WITH ‘SPECIAL NEEDS’ <ul><li>An estimated 1-in-6 American children has a complex chronic condition— </li></ul><ul><li>physical, developmental, behavioral and/or emotional—that goes beyond </li></ul><ul><li>the traditional medical services required by the pediatric population </li></ul><ul><li>generally. In addition to excellent primary care, these ‘special needs’ </li></ul><ul><li>patients need a wide range of therapeutic and supportive services from </li></ul><ul><li>multiple providers and service systems. Recognizing this situation, the </li></ul><ul><li>American Academy of Pediatrics (AAP) was the first group to call on </li></ul><ul><li>pediatricians to develop Medical Homes for children (1992) with the </li></ul><ul><li>following eight (8) main components: </li></ul><ul><ul><li>Provision of preventive care; </li></ul></ul><ul><ul><li>Assurance of around-the-clock medical care; </li></ul></ul><ul><ul><li>Continuity of care—from infancy through adolescence; </li></ul></ul><ul><ul><li>Appropriate use of subspecialty consultation/referrals; </li></ul></ul>
  10. 10. IN THE BEGINNING: MEDICAL HOMES FOR CHILDREN WITH ‘SPECIAL NEEDS’ ( cont’d) <ul><ul><li>Practice-based care coordination; </li></ul></ul><ul><ul><li>Ongoing interaction with school and community </li></ul></ul><ul><ul><li>agencies; </li></ul></ul><ul><ul><li>Central medical record and database with all </li></ul></ul><ul><ul><li>pertinent health-related information; and, </li></ul></ul><ul><ul><li>Active family involvement in decision-making. </li></ul></ul><ul><ul><li>Source : Medical Home Initiative for Children with Special Needs Project </li></ul></ul><ul><ul><li>Advisory Committee, 2002; American Academy of Pediatrics Ad Hoc Task Force on </li></ul></ul><ul><ul><li>Definition of Medical Home, 2002 </li></ul></ul>
  11. 11. MEDICAL HOMES FOR CHILDREN WITH ‘SPECIAL NEEDS’: THE EVIDENCE <ul><li>AAP has pilot tested and evaluated the model in collaboration with a </li></ul><ul><li>number of pediatric practices around the country. The results are </li></ul><ul><li>very promising. Parents of children with ‘special needs’ who have a </li></ul><ul><li>Medical Home report: </li></ul><ul><ul><li>Significantly easier access to care; </li></ul></ul><ul><ul><li>Significantly less delayed/forgone care; </li></ul></ul><ul><ul><li>Significantly fewer unmet health care needs; and, </li></ul></ul><ul><ul><li>Significantly fewer unmet family needs for </li></ul></ul><ul><ul><li>support services </li></ul></ul><ul><ul><li>Source : Pediatrics (2004), 113:5 </li></ul></ul>
  12. 12. A NEW TWIST: ‘GUIDED CARE’ FOR HI-RISK GERIATRIC PATIENTS <ul><li>Hi-risk geriatric patients have multiple, co-occurring chronic conditions and </li></ul><ul><li>functional disorders, are frail and medically/socially complex, and often </li></ul><ul><li>need a mix of health care and supportive services to maintain independent </li></ul><ul><li>community living. Quality of care can be problematic—especially since </li></ul><ul><li>PCPs with expertise in geriatric medicine are in very short supply. ‘Guided </li></ul><ul><li>Care’—developed at Johns Hopkins Bloomberg School of Public Health in </li></ul><ul><li>Baltimore, MD—is an innovative, interdisciplinary, Medical Home-like </li></ul><ul><li>model of primary care designed to improve patient-centeredness and </li></ul><ul><li>care quality/efficiency for vulnerable older people. The Guided Care model </li></ul><ul><li>integrates several previously successful clinical interventions “under one </li></ul><ul><li>roof”: </li></ul><ul><ul><li>Specially-trained Guided Care Nurse co-located </li></ul></ul><ul><ul><li>with several PCPs; </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Electronic Health Record (EHR); </li></ul></ul><ul><ul><li>Comprehensive assessment and evidence-based </li></ul></ul><ul><ul><li>care planning (e.g., care guide and action plan); </li></ul></ul>
  13. 13. A NEW TWIST: ‘GUIDED CARE’ FOR HI-RISK GERIATRIC PATIENTS (cont’d) <ul><ul><li>Emphasis on patient self-management; </li></ul></ul><ul><ul><li>Ongoing care coordination and patient monitoring </li></ul></ul><ul><ul><li>(at least monthly); </li></ul></ul><ul><ul><li>Patient coaching to promote healthy behaviors; </li></ul></ul><ul><ul><li>Smoothing of patient transitions between providers </li></ul></ul><ul><ul><li>and sites of care; </li></ul></ul><ul><ul><li>Carer education and support; and, </li></ul></ul><ul><ul><li>Enhanced access to community resources. </li></ul></ul><ul><ul><li>Sources : Aliotta et al, 2008. Also: and </li></ul></ul><ul><ul><li> </li></ul></ul>
  14. 14. ‘ GUIDED CARE’: EMERGING EVIDENCE <ul><li>Based on pilot study results and early findings from a multi-site, </li></ul><ul><li>randomized controlled trial (RCT), the effects of Guided Care—in terms of </li></ul><ul><li>quality, patient/family satisfaction, and costs—appear to be moving in the </li></ul><ul><li>right direction: </li></ul><ul><ul><li>Pilot Study: </li></ul></ul><ul><ul><li>-Patient rating of Guided Care significantly </li></ul></ul><ul><ul><li>higher than usual care; </li></ul></ul><ul><ul><li>-Reduced hospital/ED admissions and hospital days; and, </li></ul></ul><ul><ul><li>-Expenses—as measured by insurance payments—were </li></ul></ul><ul><ul><li>25% lower over a 6-month period. </li></ul></ul>
  15. 15. ‘ GUIDED CARE’: EMERGING EVIDENCE (cont’d) <ul><ul><li>RCT (Early Results): </li></ul></ul><ul><ul><li>-Patients/families were more satisfied with Guided Care </li></ul></ul><ul><ul><li>than usual care; </li></ul></ul><ul><ul><li>-PCPs were more likely to be satisfied with their patient/ </li></ul></ul><ul><ul><li>family interactions; and, </li></ul></ul><ul><ul><li>-Patients rated the quality of their health care higher than </li></ul></ul><ul><ul><li>usual care. </li></ul></ul><ul><ul><li>Sources : Boyd et al, 2007; Bouldt et al, 2008 </li></ul></ul>
  16. 16. MEDICAL HOMES FOR EVERYONE <ul><li>Over the past several years, the Medical Home concept has also found its </li></ul><ul><li>way into mainstream health care as a way to renew and reinvigorate the </li></ul><ul><li>American primary care system on both the population and clinical levels— </li></ul><ul><li>especially in the face of growing chronic illness. Multiple medical specialty </li></ul><ul><li>groups, federal/state governments, foundations and advocacy </li></ul><ul><li>organizations are promoting variations on the generic model now widely </li></ul><ul><li>known as the ‘Patient-Centered Medical Home’: </li></ul><ul><ul><li>American College of Physicians (ACP): Advanced Medical Home </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>American College of Family Physicians (ACFP): TransforMED </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Tax Relief and Health Care Act of 2006: Medical Home Demo. </li></ul></ul><ul><ul><li> </li></ul></ul>
  17. 17. MEDICAL HOMES FOR EVERYONE (cont’d) <ul><ul><li>National Committee for Quality Assurance (NCQA): </li></ul></ul><ul><ul><li>Physician Practice Connections </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Joint Principles of the Patient-Centered Medical Home: </li></ul></ul><ul><ul><li>AAFP, AAP, ACP and AOA </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>The Commonwealth Fund: Patient-Centered Primary </li></ul></ul><ul><ul><li>Care Initiative </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Community Care of North Carolina (CCNC): Medical Home </li></ul></ul><ul><ul><li>B. Steiner et al, 2008 </li></ul></ul><ul><ul><li>Available at : </li></ul></ul>
  18. 18. MEDICAL HOMES FOR EVERYONE (cont’d) <ul><ul><li>Community Care of North Carolina (CCNC): Medical Home </li></ul></ul><ul><ul><li>B. Steiner et al, 2008 </li></ul></ul><ul><ul><li>Available at : </li></ul></ul><ul><ul><li>Patient Centered Primary Care Collaborative (PCPCC) </li></ul></ul><ul><ul><li> </li></ul></ul>
  19. 19. MEDICAL HOMES FOR AMERICA: HOW CLOSE ARE WE? <ul><li>To use a term coined by Clayton Christensen, the Medical Home is a </li></ul><ul><li>“ disruptive innovation”—in a positive sense. As a potentially powerful form </li></ul><ul><li>of integration, it is designed to revitalize the American primary care </li></ul><ul><li>system—whether for vulnerable groups or the population-at-large. While </li></ul><ul><li>Medical Home offers enormous promise, it is clear that the changes </li></ul><ul><li>envisioned will not happen overnight. There are a series of medium- to </li></ul><ul><li>long-term ‘make or brake’ challenges which must be overcome before </li></ul><ul><li>becoming part of mainstream policy and practice: </li></ul><ul><ul><li>Firmly establish clinical/business cases: </li></ul></ul><ul><ul><li>-Does it really produce the impacts claimed? For </li></ul></ul><ul><ul><li>some or all patient groups? </li></ul></ul><ul><ul><li>-Is it robust enough? </li></ul></ul><ul><ul><li>-What does it really cost? Can we afford it?; </li></ul></ul><ul><ul><li>Educate/train physicians, nurses etc.; </li></ul></ul><ul><ul><li>Retrofit/upgrade primary care infrastructure and </li></ul></ul><ul><ul><li>technology; </li></ul></ul>
  20. 20. MEDICAL HOMES FOR AMERICA: HOW CLOSE ARE WE? (cont’d) <ul><ul><li>Develop access to affordable capital; </li></ul></ul><ul><ul><li>Reform health care financing/reimbursement: </li></ul></ul><ul><ul><li>-Care coordination fee? </li></ul></ul><ul><ul><li>-Pay for Performance (P4P)? </li></ul></ul><ul><ul><li>-Blended rate? </li></ul></ul><ul><ul><li>-Incentives for consumers?; </li></ul></ul><ul><ul><li>Adopt certification/accreditation standards; </li></ul></ul><ul><ul><li>Increase supply of PCPs, Advanced Practice Nurses </li></ul></ul><ul><ul><li>(APNs), Clinical Nurse Specialists (CNSs), and Nurse </li></ul></ul><ul><ul><li>Practitioners (NPs); and, </li></ul></ul>
  21. 21. MEDICAL HOMES FOR AMERICA: HOW CLOSE ARE WE? (cont’d) <ul><ul><li>Overcome other barriers: </li></ul></ul><ul><ul><li>-Public Acceptance: Threat to “freedom of choice”? </li></ul></ul><ul><ul><li>-Vested interests (e.g., specialists, disease </li></ul></ul><ul><ul><li>management/care management </li></ul></ul><ul><ul><li>providers). </li></ul></ul><ul><ul><li>Source : Christensen, 2006 </li></ul></ul>