Implementing patient centered medical home pilot projects

by Robert Graham, MD

As the nation works to reinvigorate primary care, a lot is riding on the medical home.

Some see it as an answer to a fragmented health care system that is not responsive to patients’ needs for coordinated, comprehensive care. Others have invested in it as a vehicle to improve both the quality of care and control costs. While we work to address these broad concerns, one clear lesson has already emerged from work in Cincinnati, where I chair a medical home pilot on behalf of the Health Improvement Collaborative of Greater Cincinnati – putting the medical home concept in practice is changing the doctor-patient relationship for the better.

Cincinnati is one of many communities around the country currently implementing medical home pilot programs. Our pilot aims to more fully support consumer-driven care, activating patient engagement, rationalizing and coordinating processes, and ultimately improving outcomes by educating patients to better manage their diseases and take more responsibility for improving their health. Our efforts in Cincinnati emphasize improving patient compliance, instead of just focusing on physicians.

Our work is part of a larger initiative sponsored by the Robert Wood Johnson Foundation to create models for reform. Called Aligning Forces for Quality, the initiative works to lift the overall quality of health care in 17 communities by focusing on three things: performance measurement, quality improvement and consumer engagement. The medical home model suits Aligning Forces communities well because we’re already working to measure and publicly report on the quality of local care, help providers learn how to deliver better care, and engage patients in making informed choices about the care they receive.

Similar Aligning Forces medical home pilots are also taking place in Maine and Western New York, and we each have a unique perspective on the challenges and opportunities involved in recruiting practices, supporting change, and engineering payment models that can sustain medical homes. But, we all focus on the many attributes that make primary care a locus of quality improvement: access to care, enhanced communication between patients and their health care team and care coordination.

Currently, our pilot in Cincinnati involves a mix of 11 internal and family medicine practices, representing more than 80,000 patients. An Aligning Forces work group that included local health plans, employers and providers worked together for a year to review medical home best practices and plan a model uniquely suited to our region. Three of Cincinnati’s major insurers – Anthem, Humana and United Healthcare – were involved in the pilot’s design and are now reimbursing participating practices by an agreed-upon, performance-based formula.

We began recruiting for the program in July 2009, and required each practice to do a medical home “IQ assessment” based on NCQA criteria. In fact, we made it mandatory that participating practices secure patient-centered medical home recognition from NCQA in order to take part in the project. But, in addition to monetary contributions from the three participating health plans, pilots also receive assistance from TransforMED, a subsidiary of the American Academy of Family Physicians formed specifically to assist practices with medical home transformation.

We also gave a co-pilot group of 10 additional practices not chosen for full support during the pilot the opportunity to pursue a medical home model without support from payers. They have access to resources through Aligning Forces, including the group’s learning collaborative and support with NCQA submissions.

Participating practices have spent the last year focusing on ways to address the “normal” inefficiencies that occur in practices with high utilization rates. Most have set aside a specified slot of time with the physician for walk-in appointments. This has greatly improved access to physicians. It has also helped address continuity of care issues by making it easier for patients to gain access to the primary care practice and avoid trips to the emergency room.

Practices have also moved towards team-based care where nurse clinicians, physician assistants and other personnel with well-defined clinical skills can practice at the top of their license. This allows physicians to utilize the training of their entire staff, instead of trying to do it all, and focus on the care that only a licensed physician can provide.

Although our pilot is just starting to collect patient experience data, patients have given positive feedback on spending more time with other members of the health care team, so long as they have the option to see a physician. In other words, as long as seeing a nurse practitioner isn’t interpreted as being a barrier to seeing the physician, and is instead communicated as extra attention that leads to a better primary care experience, patients react favorably.

I think the medical home model allows more time with patients that really need to see a doctor, and helps remove the pattern of seeing a new patient every 15 minutes. Instead, physicians can block their time to allow for a couple of 30 minute appointments during the day for patients with complex cases. It’s these types of patients – those with multiple chronic diseases, the non-compliant patient, etc. – that can truly benefit from the extra time and are more vulnerable to having what I like to refer to as a “medical misadventure.”

More than a year in, all of our 11 pilot practices have received recognition from NCQA; the 10 co-pilot practices will apply for recognition in March. But what this really means for these patients in Cincinnati is that they’re getting a higher level of engagement from their health care team. Overall, we’ve learned that the medical home model is not only about changing processes and structures; it’s about changing attitudes to be more patient-centered, team-based and proactive. It’s changing who you are as a physician and the relationships you have with your patients.

Robert Graham is Professor of Family Medicine in the Department of Family Medicine at the University of Cincinnati School of Medicine. He also chairs the Patient-Centered Medical Home Work Group, a part of the Health Improvement Collaborative of Greater Cincinnati’s Aligning Forces for Quality program.

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  • stargirl65

    How many of these practices are solo physician practices? Are they independent practices or part or a larger group that provides supplemental assistance to each doctor in terms of access to nutritionists, mental health specialists, etc?

  • r watkins

    Seeing same day/walk-in patients and using support staff appropriately are business as usual in well-run practtices. The sine qua non of the PCMH is the enormous administrative and bureaucratic burden that interferes with real patient care.

    Sounds like the Cincinnatti docs are seeing fewer patients and hiring more staff. This means a very quick and substantial drop in income unless the insurance company subsidies are immediate and large.

    Would be interesting to get more info here.

    Jargon like” it’s about changing attitudes to be more patient-centered, team-based and proactive. It’s changing who you are as a physician and the relationships you have with your patients” doesn’t inspire much confidence.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Dr. Graham,

    Nice post – interesting project. One of the problems with using NCQA as the PCMH standard is the lack of meaningful standards regarding what consitutes effective physician-patient communications. How are you planning to address this issue given the woeful state of physician-patient communications as documented over the last 30 years of published studies? Without addressing how patient and physicain typically communicate (or don’t), I have trouble seeing how physician PCMH-designated practices will ever realize their full potential.

    Steve Wilkins, MPH
    http:\\www.healthecommunications>wordpress.com

    • http://www.exmednav.com Mike Pierce

      Steve – You make a good point. Would you consider Shared Decision Making a viable method of addressing the patient-doctor communication issue?

      • http://www.healthecommunications.wordpress.com Steve Wilkins

        Shared decision making is one of many tools that can be brought to bear on the physician-patient communications issue of which I spoke. Like many of the other tools, i.e., “teach back,” visit agenda setting, uninterrupted opening patient statements, etc., shared decision making is useful when their are tough decisions to be made – usually about a course of treatment. That is often not the situation with the run of the mill primary care well visit for example. Speaking from personal experience, the more serious the case, i.e., lung cancer, the less interested even the most empowered patient is in “shared decision making” and decision tools. In such cases, the patient looks to the doctors as expert. I do a fair amount of patient advocacy for example for people with cancer. People I work with aren’t interested in shared decision making..they want me to tell them what they should do. There’s a time and application for every tool.

        To learn more check out my blog at http://www.healthecommunications.wordpress.com

  • jsmith

    .Lots of staff is expensive.
    So the docs are seeing only noncompliant or ubercomplex pts. Boy, that practice sounds about as fun as a migraine. Not likely to impress the med students.
    If this is the last hope for primary care, call the undertaker.

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