ACP: What I’ve learned from my medical home

ACP: What Ive learned from my medical homeA guest column by the American College of Physicians, exclusive to KevinMD.com.

Two years ago, my practice became a patient-centered medical home (PCMH), or more accurately, my practice began the transition towards delivering patient care under this new model. While that process is far from complete at this point, it’s been a positive experience. This month, I’d like to share some observations that might help those of you who are on similar journeys or still thinking about it.

Meeting expectations is harder than creating them. This became most evident when we committed to increasing access for our patients. Getting our patients to call us first before going to the ER or urgent care centers is a challenge, but an even bigger task is to develop the capacity to see those patients once they call us, often on the same day. Our approach to physician scheduling, which in a fee-for-service model is designed to fill all appointments as far in advance as possible, needs to be revamped in the era of enhanced access.

When does patient centeredness become patient dependence? For years, we’ve been reminding patients of their appointments a day or two in advance. Even though it minimizes no-shows, which can be costly to the practice, the need to do this always bothered me. Why can’t adults be accountable for keeping track of their own medical appointments, I asked. The PCMH model goes beyond making sure that patients show up. We’re now expected to track whether patients get their tests done, follow through with referrals, and take their medications. The model expects patients to be active participants and share in the responsibility for achieving these goals, but in some ways, the accountabilities appear to be physician-centered while the care is patient-centered. That is not to say that patients should be left to succeed or fail on their own, since they don’t always have the resources, health literacy, and support that they need, but we should be mindful of the risk of disenfranchising our patients instead of empowering them.

It’s hard to drive if you can’t see where you’re going. While it may be possible to succeed as a PCMH without an EHR, it’s difficult even with one. Focusing on quality and safety is a principle of the PCMH, and timely and reliable data are critical to fulfilling that principle. As I get further into this model, my need for data increases, but the limitations of the EHR and, more significantly, the lack of interoperability with my patients’ outside points of care frustrates me.

If you build it, they may not come. One year ago, we activated a patient portal that allows patients to receive their lab results and request medication refills. To my surprise, a minority of patients signed up for it and even fewer actually check their lab results. Some of that may have to do with difficulty with the user interface, but I also suspect that we may be a bit ahead of our patients in this department. However, when it works, it’s a wonderful thing.

Hiring isn’t what it used to be. In the “old days,” you could hire someone with little experience and teach them how to answer the phone, schedule appointments, put patients in examination rooms, collect copayments, and file medical documents. Today, in order to work in a PCMH, one needs to understand the concepts of team-based care, know how to use an EHR, perform health assessments, motivate and educate patients, reconcile medications, and administer injections, among other things. Sometimes I wonder if the labor force will be able to meet those needs.

It takes a neighborhood.  Success as a PCMH requires more than enhancing access, increasing patient engagement, and using data effectively. Bridging the care that patients receive outside the PCMH with what we’re trying to do in the PCMH is the greatest challenge. It’s more than the sharing of data among the many providers who are involved in a patient’s care. It means changing cultures, creating new relationships (and perhaps ending old ones), communicating differently (or starting to communicate), and rethinking how we are paid for our work. We’re just beginning to tackle this one as we become an accountable care organization (ACO). The ACP’s Patient Centered Medical Neighborhood paper  provides excellent guidance.

You can teach an old dog new tricks, but it takes time. The fact that two years later we’re only part way there is not a failure – it’s a necessity. It will probably take a few more years to finish the process, and even then, the model will continue to evolve. There is a limit to how many things you can ask your staff to do, change, or discontinue while keeping them motivated and not burning them out. As I wrote in an earlier post, it’s important to fully engage your entire team so that they understand the “why’s” as well as they understand the “what’s.” Also, let’s not overestimate our own ability to change how we do our work. As physicians, we’ve developed workflows and habits that were designed to meet the needs of a fee-for-service, episode-driven system and its associated hassles.  Some of these workflows and habits will work well in a PCMH, some less so or not at all. Just as we shouldn’t expect our team members to adapt painlessly to all of the changes, we must acknowledge the limits to our adaptability.

Hope and change. Despite the hurdles that I described, it wasn’t long after we started our transformation that I realized that I felt better about going to work every day. Delegating tasks to my medical assistants, working with a nurse care manager, knowing how I’m doing with management of chronic conditions, and having more time to spend doing the things that only a physician can do is making the practice of medicine fun again. If that were not enough, I’m also getting paid better while doing it. That’s not a bad deal.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • OETKB

    The concept PCMH is a gimmick. It is a cover for what physician’s responsibility should have been all along. In this current model it is a hand off to other agencies or individuals rather than to the physician him or herself. It will also add to cost rather than make care more efficient. Any time more professionals are added whether needed or not and retaining the same level of involvement by other professionals there is extra payroll.

    • Yul Ejnes, MD, MACP

      You are correct on a couple of points – the model acknowledges what we should have been doing (or would have liked to have done) all along. But it also pays us for doing those things, as opposed to the status quo that expects us to do those things for free. And yes, the payroll is higher under the model, but so is net income. I’d rather have that problem than the alternative.

      • OETKB

        It is not working for free. You have an office visit set up needed services and then have follow up visits as warranted. What you propose will increase costs unnecessarily and loses opportunities for strengthening doctor-patient relationships.

      • southerndoc1

        “But it also pays us for doing those things”
        Of all the problems with the PCMH, that’s the killer for most of us.
        Payment for all these extra services is completely dependent on the good will of insurers, and we have no control over if they will pay, what they will pay, and how long they continue to pay. In our area, one of 5 major payors is now offering $0.50 PMPM, the others nada. Some of the practices that have invested heavily in this are hanging on by their fingernails, the docs are stressed to the max, and the patients very unhappy.

  • jsmith

    How will you like it when the insurance company starts cutting down on the payments and they and the gov. start increasing their expectations. The PCMH is a scam to get us to work harder for less money. You’ll learn.

  • http://warmsocks.wordpress.com/ WarmSocks

    How can a doctor possibly keep track of whether a patient takes medications? You might be able to access the state’s database to see if prescriptions were filled, but there’s no way to know if the medicine was taken, dumped in the trash, given to a friend, or is sitting in the cupboard.

    Maybe the PCMH concept will lead to better compliance, since doctors will be forced into a situation where they fire patients who appear to be noncompliant.

    • southerndoc1

      “How can a doctor possibly keep track of whether a patient takes medications?”
      She can’t, but it’s a good tool to beat her with and cut her pay. And a good way to make busy work for a case manager.