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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