Who should lead the patient centered medical home?

The American Academy of Family Physicians (AAFP) took a bold stance in a report regarding the future of primary care in the US by reinforcing its endorsement of the Patient Centered Medical Home (PCMH), specifically led by physicians.  The report was supported by other large national physician organizations including the American Academy of Pediatrics, the American Medical Association, and the American Osteopathic Association.

The report took a close look at independent nurse practitioners as they have had political swing in a number of arenas to lead primary care teams and practice independently of physicians. Without surprise, the American Academy of Nurse Practitioners (AANP) “ripped” and responded (because if they did not “rip,” then a number of members probably would have wondered why).

Turf battle?  Probably.  In the best interests of the patients? Hopefully.  Does this solve any current problems?  Doubtfully.

I am currently a family medicine resident in a National Committee for Quality Assurance (NCQA) Level 3 Patient-Centered Medical Home – the highest level of medical home recognition attainable.

My experience is n=1.

Our medical home is made up of several physicians, residents, interns, nurse practitioners, physician assistants, registered nurses, and medical assistants. Mid-level providers and ancillary staff take care of the many things that should never enter the examination room, and patients can reach them 24/7/365 through a secure messaging system for refills, triage, and other questions that shouldn’t require a visit. We also have booking/check-in clerks, two case managers, a social worker, a diabetic nurse educator, a pharmacist, a psychologist, an obstetrics coordinator, coding managers, and a medical home business manager.

The physicians and nurse practitioners each have their own panel of patients. Providers are known as their patients’ primary care manager (PCM). If the PCM is unavailable when a patient wants to be seen, the patients will see another provider from our team.

PCM continuity is one of the clinic’s performance metrics. Whether the clinic is able to see a patient within 24 hours of requesting an appointment is also tracked. And a number of other performance-tracking measures are in place to monitor our ability to care for our patients – the most important metric being patient satisfaction.

In fact, since starting our medical home, patient satisfaction has increased. ER utilization has decreased. Because we use a capitated payment model – meaning the clinic is paid per patient per month, rather than per individual service provided – we are not incentivized to see 30-40 patients in a day but instead to spend more time with fewer patients.

Our medical home team has a team leader.  At any time, it can be a nurse, a physician, or whoever is available to take charge and make sure our patients are cared for.

This is the point.

Whether or not it needs to be a physician or a nurse practitioner, the evidence is definitely lacking.  However, the only thing that really sticks out to me in the IOM report for nursing and the AAFP report for the future of primary care is the idea that we should be working together in collaboration.

The national organizations can spin their reports and backlashes however they would like.  Unfortunately, this is what the media will cover.

All I know is, from my n=1 experience, physicians and nurse practitioners, as well as the many other people involved with our patients, all need to work in collaboration to provide better, more advanced and evidence-based primary care. Independent practice by nurse practitioners does not achieve this. Independent practice by physicians with limited staff does not support this.

You can go to battle to defend your turf, your ego, or whatever else may get in the way of your patients. My medical home team is going to go to battle for our patients. With my n=1 experience, I am proud to say that this is worth fighting for.

So, who is the leader in the patient centered medical home?  The answer is easy: our patients.  And they deserve increased access to a team of providers – physicians and nurse practitioners, not practicing independently – who all need to be leaders in advocating for the patient’s ability to achieve a healthier life.

Kevin Bernstein is co-founder of Future of Family Medicine.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    ‘Independent practice by physicians with limited staff does not support this.”

    I hope you understand that an n=1 experience in a particular environment does not support such a general statement. I have seen perfectly functioning solo practices, some with official PCMH recognition and many more without. There are several of those who are regular readers of this blog and I hope they contribute their 2 cents here.

    The most obvious example that comes to my mind would be a concierge practice with a small panel, where everything you described and perhaps much more, is readily available to patients. And I have just recently seen a bunch of solo pediatric practices, with huge Medicaid percentages, that could easily qualify for PCMH Level 10 if anything like that existed.

    N=1 is important, but it is rarely extensible to N >1.

  • kjindal

    the last time i read/heard something so empty it went like this:
    “why can’t we all just get along???” (Rodney King)

  • buzzkillersmith

    What, no partridge in a pear tree in your clinic? You seem to have everyone else.
    In truth, this will all come down to money. Lip service will be paid to quality of care and pt service, but that’s all baloney. It’s the money. If the PCMH does not save it, it will be yanked and we will be on the next panacea. Just hope the money saved on the ER visits pays for all that extra staff. And don’t be surprised if the payers ratchet down on the capitation over time. Those of us who have been around have seen this stuff come and go.

  • southerndoc1

    “The American Academy of Family Physicians (AAFP) took a bold stance in a report”

    The AAFP has never taken a bold stance on anything.

    Their position paper on NPs was based on absolute fear that someone may possibly want to fight them for the crumbs from the health care table.

    That they want to fight this battle indicates that they’ve already lost.

  • PamelaWibleMD

    “Patient Centered Medical Home” should be led by patients. “Physician Centered Medical Home” should be led by physicians. I’m much happier since allowing my patients and community to design my entire clinic. For the first time in my career. my job description has been written by patents, not administrators, experts, or politicians. What a relief. I finally feel like a real doctor.



  • Docbart

    Those of us who have been around the block more than a few times often say that no-one knows as much (or at least thinks they do) as a resident. It will be interesting to see how Dr. Bernstein’s views change with experience.

  • win38

    here is my n=1

    Dr X had been my doctor for three months and I had met her once for an annual physical when the clinic was chosen to participate in the TransforMed project. Dr. X was recommended to me as a doctor who really cared for her patients. Prior to my association with Dr. X, I had aquired 4 chronic conditions with one of these conditions being a “zebra” that looked like a “horse.” I had spent a great deal of time with many specialists and really needed a primary care doctor who was up to date. I need a doctor who was available for urgent needs because often times providers who had not worked with me often got it wrong.

    During the 18 months I stayed with Dr. X and the TransforMed project, I saw 5 different providers for a new issue that surfaced. At one point I had worsening symptoms come up on a Friday night and since Dr. X was not at the clinic, no one would talk to me. I came into the clinic to talk to one of the providers and was told to go to the emergency room. I was so mad, said I wasn’t going to the ER, and I left. Three days later when my symptoms persisited, I did visit the ER.

    A few days later, I wrote a letter to the clinic director about my experiences of being passed around the office. The next day a medical assistant called me to see if I wanted an appointment. No one asked me how I was, or what happened at the ER.

    And sure, I could call the clinic and be seen in within a few hours but I wouldn’t see Dr. X. At one point my “zebra” reared it’s ugly head and the nurse practitioner I saw told me I was fine. When I tried to explain what my specialist had done, I got nowhere. Eventually lab work came back that showed I had a severe infection. By the time the medical assistant called me the NP had left the building. I wasn’t sure this was the right medication and wanted to talk to someone about it. Even though Dr. X was in the building, I was told it had been more than a year since I had seen her so she wouldn’t answer my questions but I could make an appointment and come in next week. At that point I contacted my specialist to get the care I needed.

    When I developed a gynecological problem, the thought of being passed around the office became too much. I found this nice independently practicing nurse practitioner, who not only helped me with the problem at hand, but with a few others-all with compassion that was missing at the TransforMed PCMH.

    So this is patient centered care? Many times I was told that Dr. X would get information about my health. I really don’t know if that happened because I never saw Dr. X. A PCMH is just home for your chart where nobody really knows you. When nobody really know you, your priorities, your quirks, your fears that effect you medical experience are ignored.

    • southerndoc1

      Painful, and well said.

      You found out, the hard way, that the PCMH is all about payers and process, not about patients.

    • buzzkillersmith

      You might be a candidate for concierge care if you can afford it. Being able to see a doctor that knows you when you need it–those days are over, PCMH or no. There just aren’t enough of us to go around, unless you want to pay for concierge, as I said.

      • southerndoc1

        True, but it’s important to realize that the PCMH is based on reducing patient access to their doctor even more than in the average family practice. “Simple” patients (i.e., zebras masquerading as horses) are forced to see the PAs, or even required to receive their medical care by phone or e-mail. This frees up the doctor for the more important tasks of setting the agendas for the daily group huddles, and meeting with lawyers to deal with all the team’s liability issues.

        • buzzkillersmith

          Ah, the huddles. You’re a cynical as I am. Please consider that a compliment.

          • southerndoc1

            Cynical? Moi? That’s just my natural ability to tell that black is not white, and up is not down.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    She is beyond cute…. :-) Thx for link.

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