Abstract
The concept of patient-centered medical homes (PCMH) has received much traction lately. For decades, Americans have struggled with accessing health care, affording services, and handling less-than-perfect health outcomes. In light of increasing healthcare expenses and the lack of standardization, the PCMH model offers a feasible alternative and gives patients and providers new hope.
Historically, the first mention of medical home dates back to the 1960s. Since then, both US and international bodies have been making efforts to promote universal health care and shift the focus to patients and their needs. The turning point in the history of the PCMH concept was in 2010 when President Obama signed the Affordable Care Act. Its statutes contributed to the advancement of medical homes nationwide.
The model aims at lightening the financial burden caused by surging chronic illness and disability rates. Medical homes are to be staffed appropriately and given additional clinical decision support. The PCMH model ensures easy access to healthcare services by reducing wait times and allowing patients to contact providers outside inpatient settings via phone or email. The adherents of the concept believe that the transformed system will enhance health literacy in patients and eventually, will help to decrease readmission and complication rates. The PCMH model is built on compassion and patient autonomy in health management and decision-making.
For all its advantages, it might be too soon to make any conclusions about the efficiency of the proposed model. The critics of medical homes point out that implementation does not impact the quality of care significantly, nor does it cut the expenses. There should be further research on the long-term effects of the PCMH introduction. Apart from that, the concept needs tailored solutions that would fit various contexts.
Introduction
This policy memo presents the concept of patient-centered medical homes (PCHM). The model is characterized by centralization and coordination of services for a patient through his or her primary care provider (Edwards, Bitton, Hong, & Landon, 2014). PCMHs are a promising alternative to traditional healthcare models and have the potential to take health services to a whole different level. The present memo seeks to explain the rationale behind the creation of PCMH as well as outline its key functions, advantages, and disadvantages.
Patient-Centered Medical Homes: Rationale and Historical Background
While patient-centered medical homes are not exactly a novel concept, they have only started to gain attention in the last two decades. However, the history of the PCMH model dates back to the 1960s when the American Academy of Pediatrics (AAP) coined the term “medical home.” With this term, the experts sought to describe primary care that would be accessible by everyone and not only the privileged class. Other key characteristics that the AAP assigned to “medical homes” were family-centered, comprehensive, continuous, culturally effective, and compassionate (“History. Major milestones,” n.d.).
Fast forward to 1978, in their annual Primary Health Care report, the World Health Organization (WHO) acknowledges universal healthcare as one of all people’s key rights. It was not until 1996 that the US picked up on that idea, and the Institute of Medicine (IOM) published Primary Care: America’s health in a New Era report. In the said document, the IOM called for a redefinition of the philosophy of medicine and patient-provider relationships. According to the IOM, health workers were to practice in the context of family and community as well as maintain respectful and compassionate relationships with their patients (“History. Major milestones,” n.d.).
The last two decades have also been marked by significant events that advanced the cause. In 2002, national family medicine organizations launched The Future of Family Medicine project whose primary goal was to ensure that every American has access to a personal medical home. The same year, the Chronic Care Model was introduced, which provided important guidelines on how to prevent, manage, and relieve chronic conditions. In 2005, a renowned researcher and a champion for health rights, Dr. Barbara Starfield outlined key primary care mechanisms that would benefit the well-being of all Americans:
- improved access to necessary healthcare services;
- better quality of care;
- focus on prevention rather than treatment;
- early management of the disease;
- the cumulative effect of primary care providers;
- reduction in unnecessary/ redundant/ harmful services (“History. Major milestones,” n.d.).
In 2010, Barack Obama signed the Patient Protection and Affordable Care Act into law, which meant an increase in investments in medical home pilots, human resource development, and staff training. By 2012, 47 US states had adopted policies and programs to implement the medical home concept (“History. Major milestones,” n.d.). Cost and quality outcomes have yet to be analyzed to draw any consistent conclusions.
PCMH Functions
Comprehensive Care
First and foremost, providing comprehensive care implies reforming the primary care practice payment policy. Currently, the primary payment methods are limited to so-called fee-for-service arrangements. As there is a growing need to support numerous care coordination activities and resources to serve the needs of the population, these arrangements prove inadequate. The patient-centered medical home model seeks to provide support for programs that unite primary care practices and enhance their clinical capacities. This is done to improve both care providers’ and families’ autonomy in coordinating health care services. The increasing burden of disease attributed to a surge in disability and chronic condition rates may be too much for primary care clinicians to handle. The PCMH model ensures additional staff and clinical decision support to avoid burnout and turnover at medical facilities (U.S. Department of Health and Human Services, n.d.). Lastly, in the context of PCMH, comprehensive care means conducting further research to identify the most effective payment and delivery models. The adherents of the PCMH model admit that the proposed solutions are far from being universal. Instead, local research is needed to put the general guideline in perspective and make them applicable in serving the specific needs of a given community.
Patient-Centered Care
Patient-centered care means adopting a holistic approach toward providing healthcare services. In the context of the PCMH model, a health worker is prescribed to not only treat disease but to consider other aspects of a human being beyond their physical manifestation. Recovering from an illness, handling a chronic condition, and maintaining a healthy lifestyle require well-developed self-management skills and abundant mental and psychological resources. The PCMH model implies enhancing health literacy in patients and providing them with management strategies to help them become more autonomous and independent (U.S. Department of Health and Human Services, n.d.). In the best-case scenario, after discharge from the hospital or after finishing an appointment, a patient does not feel helpless or confused. Instead, he or she has an action plan and can make health decisions on their own. To make it possible, a health worker needs to simplify communication and avoid ambiguity. He or she should make the office and healthcare system environment easier to navigate and support patients’ efforts to improve their health situation.
Coordinated Care
The rapid transformation of US healthcare delivery and payment systems requires the development of coordinated care management (CM). CM is defined as a patient-centered approach that relies on the united efforts of an interdisciplinary team of specialists. The primary objective of CM is to tackle the growing complexity of care in various outpatient settings. The PCMH implies that when implementing CM, both the process and the workforce undergo innovation. CM brings about the emergence of new methods as well as new roles in the medical field. The creators of the PCMH model outline three strategies to introduce CM at national and local levels:
- identify populations with modifiable risk;
- make sure CM services are aligned with their needs;
- add and train personnel to serve the populations’ needs (U.S. Department of Health and Human Services, n.d.).
Accessible Services
The PCMH model seeks to enhance access to healthcare services for broad populations. So far, the following strategies are outlined:
- minimizing wait times. In the long perspective, early management of the disease will allow for the prevention of complications, which will lighten the financial burden and enhance patients’ quality of life;
- enhanced office hours. Patients need to be able to make appointments and still maintain their usual lifestyle, which includes school, work, child-rearing, and other commitments;
- after-hours access to providers. Counseling was found to be an effective strategy for promoting self-management of disease (U.S. Department of Health and Human Services, n.d.).
Quality and Safety
Quality improvement (QI) is one of the key concepts of the PCMH model. The creators of the model argue that engaging in QI and redesigning procedures will ensure improved quality, enhanced health, and better patient experiences and outcomes. New, reinvented procedures and activities need to be evidence-based. It is recommended to adopt the following strategies to facilitate the QI implementation:
- assess a facility’s readiness to engage;
- develop customized strategies to serve the specific needs of a given facility;
- maintain practice buy-in to promote sustained engagement in QI (U.S. Department of Health and Human Services, n.d.).
PCMH Criticism
Like any other concept, patient-centered medical homes are not devoid of flaws. It is only natural that ever since decision-makers started to take PCMH seriously and advance them on a national level, the idea has been subject to criticism. For instance, in his article, Lewis (2016) calls the PCMH model a well-intended but unsuccessful innovation. Further, he provides explains why the model is bound to fail or at the very least, never meet its ambitious expectations. According to Lewis (2016), the concept of PCMH is built around a faulty assumption that every health practitioner is ready to be a health rights champion. Namely, sustaining a meaningful patient-provider relationship, which is proclaimed to be one of the key values of the PCMH model, is based on health promotion. Yet, it takes a lot of resources and internally driven motivation to truly go beyond a definite set of work responsibilities and innovate. Another flaw emphasized by Lewis (2016) is PCMH lobbyists’ naivete regarding the time constraints of implementation. They are convinced that the model is so efficient that it will bring about change in no time.
Unfortunately, as hard data have shown, in many states, the PCMH model has yet to prove feasible. For example, a study conducted in North Carolina where Medicaid PCMH underwent significant extension revealed no reduction in relevant event rates such as hospital readmissions. Moreover, what pointed out that there was something amiss in the NC version of PCMH was that costs eventually increased and exceeded the budget. In Vermont, the PCMH implementation also barely amounted to any tangible improvements. It did not impact relevant hospital event rates, nor did it decrease healthcare expenses. What aggravated the situation is that in both cases, the post-implementation statistics were fabricated to conceal the inefficiency.
Eventually, the National Committee for Quality Assurance (NCQA) addressed the criticism and posted a response in its official blog. First, the representatives admitted that the implementation of PCMH might take much more time than expected (Bose, 2018). Thus, they argued that the studies that would focus on the long-term effects had yet to be conducted. Second, they outlined a potential growth area working on which might bring about a major change (Bose, 2018). According to the NCQA, medical hospitals underwent standard PCMH attestation, but little attention was paid to what was done to follow the guidelines (Bose, 2018). In the future, policymakers will need to ensure standardization and continuous assessment.
Conclusion
In the 21st century, the healthcare system of the United States is facing new challenges. For decades now, it has been notorious for ever-increasing prices for healthcare services and at times, subpar health outcomes. As of now, there is no doubt that the entire system is in dire need of transformation. The much-awaited change might be brought about by introducing a comprehensive patient-centered care model. The history of patient-centered medical homes dates back to the 1960s. However, the model has only started gaining traction and receive recognition in the last two decades. The primary functions of the model include providing comprehensive, patient-centered care, improving access to services, and ensuring the quality and safety of medical procedures. The critics of the concept argue that as it is now, the model is not exactly applicable and has yet to lead to any conclusive positive results. The PCMH concept might need adjustment to each facility and community that considers adopting it so that it could better serve the needs of the populations.
References
Bose, A. (2018). What’s up with PCMH? Addressing the criticisms.The National Committee for Quality Assurance. Web.
Edwards, S. T., Bitton, A., Hong, J., & Landon, B. E. (2014). Patient-centered medical home initiatives expanded in 2009–13: Providers, patients, and payment incentives increased. Health Affairs, 33(10), 1823-1831.
History. Major milestones for primary care and the medical home.(n.d.) Web.
Lewis, A. (2016). PCMH fails natural experiment.The Health Care Blog, Web.
U.S. Department of Health and Human Services. (n.d.).5 key functions of the medical home. Web.