A New Approach
Our system is in need of substantial redesign, and new approaches are required that build on existing evidence. Primary care is essential forsustainable high-performance health care and is actively redesigning its methods to provide everyone a patient-centered medical home.
The patient-centered medical home is the current platform for the substantial redesign of primary care practice, nationwide. This overhaul ofthe primary healthcare system represents an unprecedented opportunity to improve healthcare for the entire population.
Medical Home Background
The patient centered medical home is an approach to providing comprehensive primary care for children, youth and adults. The medical home is ahealthcare setting that facilitates partnerships among different healthcare professionals, including primary care providers, individualpatients and, when appropriate, the patient’s family.
The four major primary care medical societies united to outline seven joint principles for the patient-centered medical home. While behavioralhealth integration is not explicitly included in these principles, it is understood that if primary care and behavioral health are inseparable,then behavioral health must be a core element within the medical home. The two core principles of the medical home most apropos to theinclusion of behavioral health are whole person orientation and integrated service delivery.
Medical Home Joint Principles
- Personal physician — each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous andcomprehensive care.
- Physician-directed medical practice — the personal physician leads a team of individuals at the practice level who collectively takeresponsibility for the ongoing care of patients.
- Whole person orientation — the personal physician is responsible for providing for all the patient’s health care needs or takingresponsibility 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 integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home healthagencies, nursing homes) and the patientâ€™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 theindicated 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:
- Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planningprocess driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
- Evidence-based medicine and clinical decision-support tools guide decision making.
- Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement andimprovement.
- Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met.
- Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhancedcommunication.
- Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilitiesto provide patient centered services consistent with the medical home model.
- Patients and families participate in quality improvement activities at the practice level.
- Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication betweenpatients, their personal physician, and practice staff.
- Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure shouldbe based on the following framework:
- It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-facevisit.
- It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, andcommunity resources.
- It should support adoption and use of health information technology for quality improvement.
- It should support provision of enhanced communication access such as secure e-mail and telephone consultation.
- It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
- It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of theface-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
- It should recognize case mix differences in the patient population being treated within the practice.
- It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the officesetting.
- It should allow for additional payments for achieving measurable and continuous quality improvements.