How Patient-Centered Medical Homes Are Transforming Primary Care

When you hear the term Patient Centered Medical Home (PCMH), you might envision this place where providers and consultants are providing concierge service to elderly patients (who may or may not be getting their shoes shined and a nice clean shave). Sadly, this is not the case. The term patient centered medical home is simply a primary care practice with an extra focus centered around the patient. To be defined as a PCMH, a practice must exhibit five essential qualities, as defined by the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association. The practice must be: physician-led, comprehensive, coordinated, accessible, and committed to quality and safety. There are both local and national accreditation programs in place, all of which offer incentives to practices utilizing the PCMH model.

Physician-led, patient-centered
Practices under the PCMH model place a heavy emphasis on whole-person care. Patients have access to a personal physician who takes the lead in his/her care. In order to do that, the practitioner needs to really understand the patient beyond his or her medical conditions. Therefore, providers focus a little more on what is called the “social history” of a patient, which includes things like family members, marital status, living situation, career, diet, fitness, alcohol and drug use. Each patient is unique and will have specific needs. This requires providers to dig a little deeper into the patient’s background. For instance, a physician can prescribe a medication and particular diet to a patient, but s/he may not know if the patient can follow through with the treatment plan. Applicable questions may be: Does the patient have transportation? Can the patient financially afford the treatment? Has the patient failed treatment in the past?

Additionally, PCMH must fully support and embrace patients in their own education of their disease and management. In this manner, providers take on less of a consulting role and more of a counseling role in the patient’s care.

Comprehensive care
Because the PCMH is a patient’s central hub, providers have a large spectrum of care to manage. This generally includes acute care, prevention and wellness, chronic care, and end-of-life care. Practices need to be ready for sick visits, like coughs and fractures, but also need to successfully manage long-standing diseases like diabetes and hypertension. This concept isn’t anything new, but the healthcare industry has finally realized that a physician can’t do this in solitude.

To achieve such comprehensive care, practices need to bring together a large group of individuals including physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and more. Fortunately, not everyone needs to be physically present in the practice, but they have clear coordination between each other.

Now more than ever, patients are seeing multiple specialist physicians and other outside providers. If primary providers are not kept “in the loop” a patient’s care is going to get very fragmented. This particular concept requires cooperation from area hospitals, rehabilitation facilities, and nursing homes. A PCMH must be diligent in ensuring that patient records will be transferred after hospital stays or specialist visits. This means frequent quality checks on the transition of care process and also even more reliance on the cooperation of patient’s and their families.

Quality and Safety
In any industry, this is a “no-brainer.” Practices need to strive to use evidence-based medicine and include patients in decision-making in order to provide optimal care. PMCHs also need to be able to measure patient experience and outcomes then be able to improve care based on the captured data.

Patients need to be able to access someone within the practice when they need care. This means shorter wait-times, extended hours, night/weekend access via telephone or electronic device. With increasing use of patient portals, this is becoming easier and easier. Patients will always have access to their medical information and treatment details, as well as online communication with providers. Many practices already have evening hours and physicians ready to take overnight phone calls.

There are some hang-ups with the PCMH model. Though the benefits are obvious in retrospect, they require an upfront investment on part of patients and practices. Practices may have to finance hundreds of additional hours for the extra staff needed for the model. Also, consider the necessary training and technology. On the patient side, compliance will still be an issue. Social workers and case managers can only do so much to aid patients in getting housing, travel, and health coverage. Adhering to treatment plans will still be the job of the patient.

Despite these issues, it is clear to see the benefits of the PCMH model. Practices will aim to improve quality, effectiveness, and coordination for each patient, who has a unique set of needs. With an increased emphasis on prevention, PCMHs will also save patients from developing chronic diseases by intervening much earlier. This will not only improve an individual’s health, but also the community within s/he lives. Overall, patients will be better informed and get excellent coordinated care more quickly.

William Rusnak, MD's picture

William Rusnak, MD

Medical Information Advisor

William Rusnak, MD (@RusnakMD) is a resident physician in diagnostic radiology, financial investor, writer, and entrepreneur. He writes about topics such as healthcare information technology, data science, biotechnology, and prevention of chronic disease. With his involvement in several emerging healthcare companies, he is actively attempting to bridge the gap between medicine and information technology.

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