The Patient-Centered Healthcare Home

What is the Medical Home Concept?

While the medical home concept has its origins in pediatric care, the concept has expanded as the general healthcare system has contemplated the shift from a focus on episodic acute care to a focus on managing the health of defined populations, especially those living with chronic health conditions.

Several seminal commentaries influenced thinking about how team-based care might improve clinical care and achieve optimal population health, establishing the foundation for a more detailed conceptualization of the medical home:

> The Chronic Care Model, a structured approach for clinical improvement through team based care supported by an organizational and information technology infrastructure, which is the basis for the Bureau of Primary Health Care's (BPHC) Health Disparities Collaborative.
> The Institute of Medicine's (IOM) first Quality Chasm report which articulated Six Aims and Ten Rules to guide the redesign of healthcare, including the importance of team-based care. This roadmap for improving quality in the healthcare system stated that healthcare should be safe, effective, patient-centered, timely, efficient, and equitable. The Chronic Care Model, Health Disparities Collaborative and Quality Chasm Aims and Rules are described in Appendices A and B.

Building on this foundation, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association released their Joint Principles of the Patient-Centered Medical Home in 2007.

> Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.
> Physician directed medical practice - the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
> Whole person orientation - the personal physician is responsible for providing for all the patient's healthcare needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life: acute care, chronic care, preventive services, and end of life care.
> Care is coordinated and/or integrated across all elements of the complex healthcare system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
> Quality and safety are hallmarks of the medical home.
> Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff.
> Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

Barr recently summarized the rationale for the patient-centered medical home, pointing to the unwarranted variation in our nation's delivery of healthcare and the lack of relationship between what is spent and the quality of the services that are delivered. He also notes that, while research suggests a robust primary care system is a major characteristic of an efficient and high-quality healthcare system, the U.S. primary care system is uncertain, perhaps close to collapse.

Against this backdrop, Barr reviews the fast-paced development of activities to test medical home models and the establishment of coalitions that include medical professional societies, large employers, health plans, and government agencies. The pace has quickened since 2006 when the Medicare Medical Home Demonstration Project was authorized in the Tax Relief and Health Care Act. Spurred by the Medicare legislation, large health plans, as well as Medicare and Medicaid, are moving ahead with demonstration projects to test new payment methods and study the quality and cost advantages of the model. This speaks to the shared desire to develop delivery and reimbursement models that address the shortcomings of the healthcare system: "A practice recognized as a patient-centered medical home would receive compensation for the time and work physicians spend to provide comprehensive and coordinated services. This approach is distinctly different from the current system which pays for !
procedures and treatment of individual diseases rather than valuing and encouraging treatment of the whole patient, preventing chronic illness, and managing multiple, interrelated and ongoing health problems."

In early 2008, the National Committee for Quality Assurance (NCQA) announced the development of standards for medical practices that wish to be certified as patient-centered medical homes. The NCQA Physician Practice Connections and Patient-Centered Medical Home materials articulate nine Standards for practices to meet, including use of patient self management support, care management, evidence-based guidelines for chronic conditions and performance reporting and improvement.

Why is Care Management Important?

At the core of the patient-centered medical home clinical approach is team based care that provides care management and supports individuals in their self management goals. In a report prepared for the Commonwealth Fund, care management was identified as being among the few policy options that hold promise not only of containing costs but also of improving health outcomes for high-risk populations.

"Care management is the coordination of care in order to reduce fragmentation and unnecessary use of services, prevent avoidable conditions, and promote independence and self-care. Alternatively called advanced care management, targeted case management, high-cost or high-risk case management, care coordination, disease management, and other terms, care management programs manifest themselves in a wide variety of ways. In one project, care management encompassed personalized nurse counseling, pharmacy review, utilization management, case management, and depression management programs."

This emphasis on self-care resonates with the behavioral health system's movement towards a Recovery and Resilience orientation, utilizing approaches such as the newly revised Wellness Management and Recovery program or Copeland's Wellness Recovery Action Plan. With these models, the behavioral health field has developed structured approaches that strengthen the individual's capacity to set goals for improved self management of specific conditions and to problem solve barriers using the resources of the community and personal support systems in addition to formal services. These approaches are critical to meeting the needs of people living with serious mental illness as well as chronic health conditions.

The five clinical functions of the care manager, as identified in the BPHC Health Disparities Collaborative, are:

> Develop and maintain rapport with patient and provider
> Educate the patient and the family
> Monitor symptoms and communicate findings to provider
> Develop and maintain a self-care action plan
> Maximize adherence to the treatment plan through negotiation of solutions to treatment-emergent problems

Unlike disease management models with arms-length, telephonic care management, in the Chronic Care Model and patient-centered medical home the care manager is embedded in the clinical team.

The community health centers participating in the Health Disparities Collaborative have also identified the importance of enabling services in helping engage and support individuals with chronic health conditions. These are non-medical services that facilitate access to timely and appropriate medical care, including transportation, language assistance, case management, and community outreach and education. This set of activities is ancillary to the focused care management task of monitoring health status and calibrating care for an individual and is generally not performed by the care manager. However, the team's success in managing chronic health conditions depends on the provision of these enabling services alongside the clinical services.

Care management is the key to transforming a healthcare system geared towards acute problems into one focused on addressing health needs from a longitudinal perspective (i.e. managing chronic illness and facilitating preventative self-care). Longitudinal monitoring and timely response to the course of illness is how care management transforms treatment as usual. This focus on ongoing accountability and responsibility for individuals being cared for should be distinguished from old ideas about "gatekeeping" access to care-a distinction confounded by the varying ways in which the terms care manager and case manager have been used in the last twenty years.