The American College of Physicians, or ACP, recently released a policy paper that calls for the inclusion and cooperation of subspecialist physicians and other health care professionals in the patient-centered medical home, or PCMH, model of care.
In an Oct. 12 press release(www.acponline.org) introducing the paper, "The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices(www.acponline.org)," ACP President Fred Ralston, M.D., said patients need primary care practices to operate as the "central hub" for their health care information. "For a PCMH to be functioning properly, it must have an effective relationship with specialty/subspecialty physicians, hospitals, pharmacists, care managers and others," he said.
The ACP uses the phrase "PCMH neighbor," or "PCMH-N," liberally in the policy paper. It defines the term as a specialty or subspecialty medical practice that
- ensures effective communication, coordination, and integration with PCMH practices;
- secures appropriate and timely consultations and referrals that complement the aims of the PCMH practice;
- confirms the appropriate flow of necessary patient and care information;
- guides determination of responsibility in comanagement situations;
- supports patient-centered care, enhanced care access, and high-quality, safe care;
- recognizes the PCMH practice as the provider of the patient's primary care; and
- understands that the PCMH practice has overall responsibility for coordination and integration of care provided to the patient.
The position paper also lays out a framework for the various ways in which clinical interactions between the PCMH and the PCMH-N take place, such as a preconsultation exchange designed to expedite or prioritize care; a formal consultation to deal with a discrete question or procedure; or transfer of the patient to the PCMH-N for the entirety of care. Transfer of the patient would require consultation with the patient's personal PCMH physician, as well as approval by the patient.
The paper also addresses the topic of comanagement of patients between the PCMH and the PCMH-N. Comanagement can be handled in one of three ways: with shared management of a disease, principal care of a disease, or principal care of the patient for a consuming illness for a limited period.
The ACP provides a 10-point list of guiding principles for the development of care coordination agreements between PCMH and PCMH-N practices. For example, the agreement should
- define expectations regarding information content requirements and the frequency of information flow within the referral process;
- specify how secondary referrals will be handled;
- maintain a patient-centered approach, including consideration of patient and family choices;
- address situations of self-referral by the patient to a PCMH-N practice; and
- clarify inpatient processes, including notification of hospital admission.
According to AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, most family physicians readily accept that patients with some special medical needs require additional help outside of the PCMH structure.
In an interview with AAFP News Now, he cited certain situations -- such as patients in certain stages of cancer care and other severe-stage illnesses -- as examples of the value of the PCMH-N concept. "In those circumstances, the expected roles will have to be flexible enough for both the patients and the physicians involved to achieve the best care," he said.
The ACP also supports the alignment of incentives -- both financial and nonfinancial --between PCMH and PCMH-N practices, as well as future work to develop a PCMH-N recognition process.
"The AAFP has long been in favor of aligned incentives to appropriately develop a high-quality, cost-effective delivery system, because lack of such incentives slows needed changes," said Goertz.
Regarding PCMH-N recognition, Goertz suggested that the topic should be tackled by those most affected by such a system. "Any decisions made should be based on how the best quality of care can be achieved."