Nadereh Pourat, PhD
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In a country where the primary-care infrastructure is stretched to its limit and some 60-million people report that they have no regular doctor or clinic where they can go to receive medical care, the medical home may be a concept whose time has come.
The patient-centered medical home concept has gained traction in recent years amid mounting pressure to eliminate unnecessary healthcare costs and improve the quality of care — particularly for individuals with chronic conditions. The basic principles can be interpreted differently. But the patient-centered medical home focuses on a more coordinated, proactive approach to primary care involving a primary-care physician working with a team of providers and a treatment plan developed with the patient. Health-policy researcher Nadereh Pourat, PhD, has examined the topic of the patient-centered medical home, finding, most recently, that patients with chronic conditions who are in such environments are more likely to receive key preventive services such as an annual flu shot. U Magazine contributing writer Dan Gordon spoke with Dr. Pourat about the potential benefits of the patient-centered medical home, what the evidence shows and its future place in the U.S. healthcare system.
What is meant by the patient-centered medical home?
It’s actually an old approach that has been brought back and is now being applied beyond its original context. As far back as the 1960s, this concept was brought up as a way to better manage children with special healthcare conditions and needs who require complex care. The goal is to manage the patient proactively, rather than providing services on an as-needed basis, which has typically been the approach we have had in the United States. For example, a patient with diabetes who is experiencing a problem comes in; the doctor examines the patient, provides advice, maybe prescribes medication; and the patient goes home until the next time there’s a crisis. The patient-centered medical home turns that approach around by anticipating the kinds of care individual patients will need, teaching patients how to take care of themselves, and having patients serve as partners in their own care as opposed to being given doctor’s instructions that may not work well for them. Now, a number of different interest groups, including physician organizations, have reintroduced this idea as a way of managing populations with chronic conditions, particularly adults.
If I have a primary-care physician who coordinates my care, does that mean I have a medical home?
It is more than that. We used to talk about the usual source of care as being the place you typically go for care where they keep your information, your chart. In the medical home, the provider would do a lot more beyond just waiting for you to show up for your next visit. First of all, a team of experts would be taking care of you. If you have diabetes, you might have, in addition to your physician, a nutritionist on the team, along with a medical assistant who calls to remind you about upcoming visits to get your blood pressure, cholesterol and blood sugar checked, as well as to ensure you are taking your medications. A nurse might be calling to make sure your feet are being checked for neuropathy. So it is a comprehensive team of providers — some of them operating behind the scenes, some of them in direct contact with the patient — who are helping to make sure patients are being managed appropriately.
Does this concept extend beyond routine office visits?
Yes. The orientation should be the whole person. In other words, the focus is not only on the patient’s condition, but also on the patient’s entire spectrum of needs. A strong element of coordination should exist among the primary-care doctor, specialists, and all of the other potential services that the patient requires, including those that are delivered in the community. The patient might be sent to nutrition classes or social-support services outside of the medical home. Utilization of services should be closely monitored so that a strong focus remains on improving quality of care. If the patient is hospitalized, the hospital and the physician should communicate about the services the patient received and what needs to be done to keep the patient out of the hospital the next time. If the patient is referred to a specialist, that specialist and the medical-home providers need to be in close contact. Much of the quality-assurance focus has to do with infrastructure: a health-information-technology system with information on the patient along with guidelines for the providers on managing that individual.
What is meant by “patient-centered” in this context?
The patient centeredness comes from the individual participating in the decision-making. It’s not just your doctor telling a patient, “This is what I want you to do.” Just telling a patient to change his or her diet and exercise isn’t necessarily going to work; the patient needs to participate in his or her own care and buy into the plan. Being patient-centered means sitting down with patients, asking about their daily routines, helping them develop a plan that they think can work for them, and then adjusting that plan over time. That’s a strategy that’s much more likely to be successful.
Are there specific guidelines determining what constitutes a medical home?
These ideas, when they were introduced, were not fully articulated. Now organizations such as the National Committee for Quality Assurance have specified what this means and are developing implementation steps. Although standards are being developed, the term is still used very loosely. More organizations are offering facilities recognition as a medical home, but it’s voluntary.
What is the advantage of receiving such a designation?
The key advantage will be when payment is associated with being a medical home. Some health plans and other organizations are beginning to think about using the medical home as a basis for structuring reimbursements, and their numbers are probably going to expand under healthcare reform.
Do you think this concept is going to expand?
We have to change how we approach care delivery, particularly in the primary-care setting, if we are to achieve the triple aims of healthcare reform — better quality, better health and lower costs. There is a lot of pressure to reduce costs, and healthcare reform adds to that pressure because now we are going to be covering more people. The patient-centered medical home brings a new opportunity; the trick is going to be how to implement it. Let’s use the diabetes example again, since that is such a prevalent condition. The early evidence indicates that if a patient with diabetes is being cared for proactively by a team of providers in a medical home, that patient is much less likely to develop more severe conditions and is more likely to stay out of the emergency room and the hospital, both of which are a costly way to receive healthcare. If that is the case, we’re going to realize some savings.
Can this approach be beneficial for patients who don’t have chronic conditions?
People who don’t have chronic conditions probably won’t see much change, but it could have positive spillover effects. For example, a medical home should be proactive in making sure patients are receiving their preventive services. Some, such as the annual flu shot, can keep one from developing life-threatening conditions. Other services, such as cancer screenings, aim to catch the disease early. The medical home also can help healthy populations focus on lifestyle and diet changes. If you are overweight or a smoker, you may not have a chronic condition today, but if you continue to be overweight, you will likely develop one over time. If your medical home takes a proactive approach and has additional services aimed at its chronic patients, then you can benefit from those services as well, whether it’s a nutritionist to help you eat better or a smoking-cessation program.
How much evidence supports this approach?
It is early, but it’s starting to build. The early evidence is promising with regard to improving quality by providing the right services — the process measures. Some evidence shows improved outcomes and reduced hospitalizations and visits to the emergency room. But it’s still too early to conclude what aspects of the medical home lead to these improvements.
What, then, are the most pressing unanswered questions?
How are providers implementing the medical home, and which providers are doing it? Is it happening in the private-insurance sector or in the safety-net system where people have fewer resources and often have more uncontrolled chronic conditions? Are those who are implementing the medical home getting results in terms of improvements in health, quality of care and costs?
What was the aim of your study on the impact of medical homes on patients receiving flu shots?
Using data from the biannual California Health Interview Survey, we estimated which Californians with chronic conditions such as diabetes, asthma and heart disease receive three key characteristics of medical-home care. They include: having a regular doctor rather than switching from provider to provider; having that doctor coordinate the patient’s care; and having that regular doctor develop an individual treatment plan for the patient. We used the flu shot as an indicator of whether or not people were receiving important preventive services. And we found that the rate of flu shots was highest among adults with chronic conditions who reported having all three medical-home characteristics, at 59 percent. In comparison, only 26 percent of adults with chronic conditions without any of the three characteristics received the flu shot. We also found that those with all three medical-home characteristics were more likely to have seen their doctor five or more times in the past year and to have called their doctor with a question about their care. They were the most confident about their ability to manage their health.
What lessons can be taken from these findings?
This was data from 2009, which was before efforts to implement medical homes began to intensify, so it allowed us to see the point from which we were starting. These findings suggest that seeing the same doctor over time builds familiarity, trust and confidence. And if that doctor takes a coordinated approach to the patient’s care, there seems to be a big payoff in terms of better health — and cost. In a nutshell, giving patients, especially those with complex conditions, a medical place to call “home” may not only keep them healthier, it also may contribute to keeping our health system solvent.