In the race to put fee-for-service payments in the rear view mirror, patient-centered medical homes (PCMHs) are emerging as an important alternative care delivery model, and many family medicine practices are implementing the concept.
Family physician Harry Strothers III, M.D.
Harry Strothers III, M.D., recently discussed with AAFP News how medical homes are revamping the delivery of health care in the United States and how physician practices can make the transformation to the new model. Strothers is professor and chair of the department of family medicine at the Morehouse School of Medicine in Atlanta and has a special interest in the PCMH model. His own practice has been recognized as a PCMH by the National Committee for Quality Assurance since 2012, and he writes and lectures extensively on the topic.
As past president of the Georgia AFP, Strothers played a key role in helping to launch the state's "PCMH University" using seed money provided by the chapter in 2010. Back then, four practices in the state were recognized as PCMHs. By 2013, that number had grown to more than 100.
Q: Expectations are high for patient-centered medical homes, but experts caution that it could take as long as five years to see noticeable results. What would you consider a reasonable timetable for results?
A: When a practice undergoes a transformation like (becoming) a patient-centered medical home, the results will vary in time from almost immediate to several years. While a well-planned and organized transformation can show results within months in terms of improved patient flow; staff and provider satisfaction; and efficient handling of labs, referrals and medication refills, seeing measurable results in care management and risk-stratified patient care can take years.
Q: What type of practice is the PCMH model best suited for?
A: While some aspects of the PCMH, like empowering staff to work at the full extent of their license or experience, can be applied to most practices, it appears that the model is best suited for practices in which most of the patients are interested in long-term continuity of care. The patients want to establish a relationship with the practice as long as they live in the area.
Practices need to build and maintain relationships with patients over a period of several years to see real results. Trying to expand the practice with more patients who only visit once for an annual physical will not improve overall community health.
Q: Can small practices make it work?
A: Yes, with the right leadership and commitment, the PCMH model can work in small practices -- for the patients and the practice. Each employee accepts greater responsibility for patient care. If the practice does not have someone who is licensed to be a care manager, then somebody on staff will be charged with handling communications with patients and will help facilitate referrals.
The education level of staff members in smaller or rural practices is usually not as formal. The care manager may not be an RN or a licensed care manager, but she knows the community and can convince patients to do what they should be doing in the first place. The care manager knows Mrs. Jones never keeps her appointments unless you encourage her to make it in.
Q: How does the medical home model change patient care?
A: Instead of focusing entirely on treatment, the practice sets a goal of keeping patients healthy. You are not just taking care of patients who show up in the office but are counting everybody you've seen as being patients and trying to take of whatever their needs are.
The scope of care is broadened to include ongoing healing relationships, whole-person orientation, incorporating a family and community context, and comprehensive and coordinated care. You meet with the patient and say, "Now that we've been polite with each other, what's really happening with your life, and what do we need to address today?"
You are advising (patients) on their diet, encouraging them to exercise, emphasizing the importance of taking their medication -- all the factors that contribute to maintaining health. These messages don't have to come from a physician, but they need to be reinforced by someone. They can be delivered by a care coordinator. I don't have to teach patients about diet because I have nurses who are licensed or professionals from Weight Watchers that patients will actually believe. They can tell the patient that (he or she) lost 30 pounds.
Patients have a clear path to ensure their continued access to care, and they are engaged in shared decision-making. The practice supports patient self-management of pain or illness. For some patients, it makes a difference, while others think they aren't sick and don't need care. One of my patients says she doesn't "own having diabetes" (and) her blood sugar is 320. It may take a while for you to get through to them.
Q: In medical homes you are familiar with, how often does a physician or other health professional communicate with patients?
A: It depends on the needs of the patient. A patient who was discharged from the hospital recently, is battling unstable disease symptoms or is experiencing some other acute health challenge might be contacted several times a week. Patients with no chronic diseases may only be contacted regarding scheduling of follow-up for age- and gender-appropriate preventive services.
The practice engages in risk-stratified care. For a 50-year-old man with no history of disease, the only issues we contact him about are flu shots and a colonoscopy. If the patient has end-stage renal disease, a bad lung or coronary artery disease, we contact (that individual) every few days based upon the medical and social risks and our evaluation of the situation.
Q: Regarding payment, how long does it take a physician practice to make the transition from strictly fee-for-service to payment types associated with the new model, and what associated changes need to occur inside the practice?
A: It depends on both the environment inside of your practice and existing resources. In markets where there are incentive payments for PCMH status, quality bonuses and/or shared savings, practices have made the transformation in less than 18 months.
Practices that need to implement a new (electronic health records) system, that don't have effective leadership, or that have financial barriers usually require significantly more time.
In addition to the practice changes included in the PCMH model, a change in mindset is necessary whereby the practice embraces caring for all patients in the practice, not just the ones who show up (regularly) for appointments. The practice must recognize that it should work as a team to improve the health of its entire patient population.
Q: Do the payment models for a PCMH provide enough incentive to continue accepting patients or does the practice have to cap the number of patients during the transition?
A: The payment models for a PCMH still vary across the country. In markets where there are incentive payments for PCMH status, quality bonuses and/or shared savings, practices are sometimes limited by the number of patients the practice can serve effectively rather than the payment model.
Your practice can only handle so many patients given the available space and the number of physicians on staff. In some advanced markets, practices can't see any more patients than they currently have and continue to provide the proper amount of care.
In places like Atlanta, it can be a struggle. You get greater satisfaction among the staff and the physicians even though it's not as satisfying financially. In other locations, insufficient PCMH payment models have restricted the number of patients that the practice can provide appropriate care management for.
Q: In terms of individual patient health outcomes and patient population health management, what results have you seen from the time you began implementing the PCMH concept until now?
A: We noticed improvements in completion of more preventive services, notably for patients who need mammograms, pap smears or a colonoscopy. Patients in need of (services called for in) disease-specific guidelines, such as hemoglobin tests or lipid panels, are receiving them in greater numbers. The rates for 30-day hospital readmissions have been reduced considerably.
The practice can catch people who would have dropped out despite still needing care. We can set more time between appointments. It used to be three months for a follow-up appointment, and now it is four to six months as long as someone in the practice can check up on the patient. We are pulling in people who did not come in when they should have or missed an appointment. They are the ones you don't see until the next time they crash.
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