FPs Carry PCMH Model Forward on State, Local Levels

The nation's family physicians have emerged as major catalysts in promoting the patient-centered medical home, or PCMH, model on the state and local levels, using both their advocacy and leadership skills to thrust the PCMH to the forefront of health care reform.

In multiple states and scores of localities, public and private payers have launched PCMH initiatives that, in many cases, are led, managed or otherwise influenced by family physicians. For example, no fewer than four PCMH pilots currently are taking place in Colorado, and family physicians play key advocacy roles in each of those initiatives, according to Raquel Rosen, M.A., EVP of the Colorado AFP.

"They talk to legislators regarding the value and importance of the medical home and the need for payment reform to sustain this model," Rosen explained.

"I don't know anyone in the health care world who is better positioned or more informed (about) knowing what patients need than family physicians," said Scott Hammond, M.D., of Westminster, Colo. "It is our mission to be the glue and connect all of the dots of the health care world and to help patients get the right care, at the right time, at the right place."

Hammond's practice -- the Westminster Medical Clinic -- is a recognized medical home and one of 16 PCMH practices involved in a project funded by the state's largest private insurance providers. Hammond served on the steering committee and the physician advisory committee for the project, helping to develop quality metrics for the program and determine the per-member, per-month fee for participating practices.

He is convinced that the PCMH model represents the paradigm for practice transformation. "I wanted to redesign my practice to be efficient and effective and to be on the cutting edge for payment reform," he told AAFP News Now.

"I feel with the PCMH, I'm in control of the care that I deliver, and I'm in the best position to provide the best care to my patients," Hammond said.

Hammond, whose clinic was recognized as a medical home in 2009, readily acknowledges that his practice faced challenges when making the transition. One of the biggest challenges, he said, was developing a vision for the practice and sharing that vision to obtain buy-in from colleagues and staff.

"We spent a lot of time involving our staff each step of the way, explaining the patient-centered medical home, how it affects their job, and how they are part of the health care team," he said.

When it comes to that health care team, most physicians are convinced they are natural team players, said Hammond, but that's not necessarily the case. "Physicians may not understand how to communicate or engage their staffs," he said. "I did not."

So he studied books and articles on making and leading transformative change, enabling him to communicate more effectively with his staff. As he began the transformation process, he quickly identified team-building opportunities and created a patient registry -- both key components of the medical home -- and focused initially on these areas.

"If you don't have these working well, then you are not really going to be a very good patient-centered medical home," said Hammond.

Since beginning the pilot, Hammond's practice has registered quality improvement gains in diabetes and cardiovascular care measures. In 2009, for example, 24 percent of his patients had a hemoglobin A1c greater than 9 percent. By June 2011, that figure had fallen to 14 percent. Also in 2009, 79 percent of Hammond's patients received nephropathy screening, a percentage that had increased to 90 percent by June of this year.

Similarly, 75 percent of Hammond's patients with cardiovascular disease were on statin therapy in January of last year; that figure had risen to 95 percent as of June 2011. And, in June 2010, 72 percent of patients with cardiovascular disease used aspirin or an antiplatelet medication regularly, a percentage that has since climbed to 87 percent.

In addition, according to Hammond, his practice is more financially viable, and staff members are happier. "I thought we had good teamwork before the medical home, but I never really understood what teamwork was until we became a PCMH," said Hammond.

"It has been very satisfying to see how the staff have grown in their professional careers and how they have become more engaged in patient care by learning to think for themselves and to be active participants in patient care, as opposed to just doing their jobs."

At the same time, Hammond said he is able to practice medicine the way he was trained to practice. "Personally, it has been a relief to be able to enjoy being a physician again," he said.

Family physicians in other states also are taking leadership roles in promoting the PCMH to state lawmakers. In Ohio, for example, family physician Ted Wymyslo, M.D., of Columbus, worked closely last year with (then) state Rep. Peggy Lehner to draft a bill to create a PCMH pilot project that involved 44 primary care practices across the state.

Gov. Ted Strickland signed the bill into law on June 8, 2010, but it wasn't until earlier this year that the Ohio legislature awarded a $300,000 grant for the pilot. That's enough money to choose the participating practices and seek additional funding while moving the project forward, according to Ann Spicer, EVP of the Ohio AFP.

Aside from the PCMH pilot, the law also calls for medical and nursing schools to incorporate tenets of the medical home into their curricula and makes nursing and medical school students pursuing a career in primary care eligible for the Choose Ohio First Scholarship program.

Wymyslo, who was named director of the Ohio Department of Health in early 2011, was heavily involved in ensuring the bill's enactment, helping to organize a cadre of family physicians who campaigned for the bill on the local level and testified before House and Senate committees. "It took us over a year to get this (measure) through the House and Senate," he told AAFP News Now. "We went through nine revisions of it in the course of getting feedback from interested parties."

At the time the legislation was enacted, there were PCMH pilots taking place in Cincinnati, Columbus and Cleveland, but the rest of the state "was largely quiet," said Wymyslo.

"I was very concerned that the state would not be prepared as a whole for the evolution in health care that is coming, meaning we would only have pockets of preparation in large cities, but the rest of the state would not be available or ready to provide medical home care -- even if patients said they wanted it and insurers said they would pay for it," he explained.

With the passage of the medical home measure, however, officials are now in a position to spread the PCMH concept throughout the entire state, Wymyslo said.

Wymyslo's support for the PCMH comes from personal experience. Before becoming the state's health department director, he ran a family medicine residency program at Miami Valley Hospital in Dayton for 22 years. In recent years, the residency began structuring itself according to the PCMH model.

"I was living in a practice that was designed with that model," said Wymyslo. "Once you have experienced it, you want everyone to experience the practice of medicine this way. I found it very satisfying, and I found my patients to be very responsive to this model."

Realizing that one of the most important parts of the PCMH is patient engagement, Wymyslo encouraged his patients to use a patient portal to electronically access their medical records whenever they wanted. Patients who used the portal became more involved in and knowledgeable about their own care. They also were able to e-mail Wymyslo questions, making it possible for him to respond in a timely and comprehensive manner and in a way he could not do over the telephone.

"It is fun to work with patients who are very much involved in directing their own care versus (being) passive recipients of the care I provide," said Wymyslo. "The patient has a tremendous advantage in this model (compared with) what they have in a (model that uses a) more passive paper record where I hold all of the information."

Despite his own positive experiences, Wymyslo is well aware that some family physicians hesitate to adopt the medical home concept because of the initial time and financial commitments involved and the concern that they may not reap financial benefits from embracing the model.

"It requires tremendous change for staff and for the physicians," he acknowledged. "That is why everyone is not a medical home yet."

When Wymyslo encounters a patient or even a family physician who has not bought into the PCMH concept, he said he usually advises them to seek care from a PCMH practice so they can experience firsthand what the model offers.

"People who really get into a medical home can see the difference and feel it and experience it," he said. "But if they just read about it, they will never quite understand why it is so important and so effective and so different from what they are doing right now."

As the state health department director, Wymyslo also encourages the governor's cabinet officials to access care from the medical home. "If we can help more people live this experience, I believe it will make it real for them and more people will insist on this experience for their families," he explained.

Meanwhile, one of the best examples of how the PCMH can improve health care quality and save costs can be found some 500 miles to the southeast. Community Care of North Carolina, or CCNC, was launched in 1998 to serve the state's Medicaid patients. Since its inception, the program has been based on physician-led networks and patient-centered medical homes.

In the past 13 years, CCNC has expanded throughout the state, encompassing 14 networks, 4,500 primary care physicians and more than 1,400 medical homes that deliver care to most of the state's Medicaid population. In the process, the program has saved billions in health care costs, according to Allen Dobson, M.D., of Concord, a family physician and former assistant secretary for health policy and medical assistance at the North Carolina Department of Health and Human Services.

"If you look at where a lot of the savings in the aged, blind and disabled have come from, the biggest part is preventing avoidable hospitalizations, not readmissions," said Dobson, who was instrumental in developing and overseeing the growth of CCNC and now serves as the president of North Carolina Community Care Networks Inc., which manages the program's networks. "Everybody is talking about avoiding readmissions, but most of our savings have been (from) reducing the rate of hospitalizations, at least with these patients who are high need.

"That is easy to understand, since access to a primary care doctor keeps people healthy," he added.

In many instances, family physicians lead the local networks, a job they are ideally suited for, according to Dobson.

"The uniqueness of family physicians is that they have a real grasp of that entire continuum of care and the needs of their patients," he said.

Family physician Jim Jones, M.D., of Hampstead, N.C., is one such network leader, serving as clinical director of Community Care of the Lower Cape Fear, which includes 137 primary care practices and covers six counties.

Jones oversees the network's operations, developing and disseminating treatment guidelines to improve practice performance and patient outcomes. He also works closely with the network's care managers. Each network employs care managers who work with patients to reinforce physicians' and other providers' plans of treatment, assist with medications and care coordination, and enable them to better manage their chronic conditions.

If, for example, a Medicaid patient with asthma who is enrolled in CCNC seeks care for his or her condition from a hospital ER instead of the designated medical home, that patient's care manager contacts the patient to find out what needs to be done to bring the patient back to the medical home for care.

"Maybe there is a medication complication or a transportation problem," Jones explained. "The care manager works out some strategy for addressing that.

"They are essential to everything we do, dissolving the fragmentation that occurs between providers, hospitals and homes."

Jones points out that the nature of the medical home actually creates a demand for primary care physicians that cannot be met by the existing number of primary care physicians. "There are simply not enough primary care physicians in the marketplace today to give every American a medical home," Jones said. "That is a big downside."