Transforming primary care: improving on the medical home model

Department of Health Studies, University of Chicago, Chicago, USAINTRODUCTIONGiven the convergence of exponential spending on healthcare in the US, poor health outcomes relative to othercountries, an aging population, and outdated methods ofdelivering primary care, there is no better time forinstituting a ‘‘disruptive’’ innovation in primary careredesign than the present (Christensen, Bohmer, & Kenagy,2000). In the midst of health reform in the US, the conceptof the patient-centered medical home (PCMH) is garneringsigniﬁcant attention as a potential solution to addressﬁnancial and performance issues (Vincent & Velkoff, 2010).While the model has worthy attributes, including anemphasis on care coordination and patient engagement,recent studies highlight the gaps and limitations in theexisting approaches (Nutting et al., 2009; Rogers, 2008).Some of these gaps and limitations in the traditional PCMHmodel include difﬁculties in accomplishing shared decisionmaking with the patient and health care team, effectivecommunication across services, and offering a broad rangeof health care services.The authors propose an alternative, primary care redesignmodel intended to build on the strengths of the PCMH modeland address some of the current shortcomings in implemen-tation. This alternative model is designed to improve patienthealth and satisfaction, while decreasing costs and may beparticularly effective among the frail elderly.THE PATIENT CENTERED MEDICAL HOME MODELAlthough considered by many to be a new idea, the medicalhome concept was ﬁrst introduced in 1967. A review of theprinciples, standards, position papers, and projects to datereveals several themes required of a PCMH. Basic criteriainclude (a) directly provided services, (b) physiciancoordination of care, (c) patient involvement in planningcare, and (d) collecting, sharing, and monitoring data toimprove care.Limitations in how this model is operationalized havebeen highlighted in recent research (Nutting et al., 2009;Sinsky, Sinksy, Althaus, Tranei, & Thiltgen, 2010). Directlyprovided services in current PCMH models are typicallylimited to primary care and laboratory testing. Second, aPCMH requires new skills for many physicians in carecoordination and management and working in teams withshared decision making. Finally, most PCMH practices dolittle to assess the home and community factors affectingthe patient’s health (American College of Physicians, 2005;Fields, Leshen, & Patel, 2010; Nutting et al., 2009; Rogers,2008).However, recent research ﬁndings suggest that a healthcare system of higher quality at lower cost will require: easyaccess, a wide array of services offered by the primary carefacility, care provided over sustained periods of time, carethat is coordinated amongst various disciplines/services,and patient-focused care with an orientation to family andcommunity needs (Fields et al., 2010; Nutting et al., 2009).Although PCMH models are beginning to emerge thataddress some of these requirements, none to date has beenable to incorporate all of these within one model. Theauthors propose an alternative primary care delivery modelthat is consistent with higher quality/lower cost healthsystem research ﬁndings and builds on the strengths of thePCMH model, while striving to overcome its implementa-tion challenges.AN ALTERNATIVE MODEL OF PRIMARY CARECare Plus, an alternative to the traditional PCMH model, isdeﬁned as a ‘‘patient-centered health care home’’ model thatincludes a wide array of directly provided primary care andsupport services, coordination by a community health


THE PATIENT CENTERED MEDICAL HOME MODEL
Although considered by many to be a new idea, the medical home concept was first introduced in 1967. A review of the principles, standards, position papers, and projects to date reveals several themes required of a PCMH. Basic criteria include (a) directly provided services, (b) physician coordination of care, (c) patient involvement in planning care, and (d) collecting, sharing, and monitoring data to improve care.
Limitations in how this model is operationalized have been highlighted in recent research (Nutting et al., 2009;Sinsky, Sinksy, Althaus, Tranei, & Thiltgen, 2010). Directly provided services in current PCMH models are typically limited to primary care and laboratory testing. Second, a PCMH requires new skills for many physicians in care coordination and management and working in teams with shared decision making. Finally, most PCMH practices do little to assess the home and community factors affecting the patient's health (American College of Physicians, 2005;Fields, Leshen, & Patel, 2010;Nutting et al., 2009;Rogers, 2008).
However, recent research findings suggest that a health care system of higher quality at lower cost will require: easy access, a wide array of services offered by the primary care facility, care provided over sustained periods of time, care that is coordinated amongst various disciplines/services, and patient-focused care with an orientation to family and community needs (Fields et al., 2010;Nutting et al., 2009).
Although PCMH models are beginning to emerge that address some of these requirements, none to date has been able to incorporate all of these within one model. The authors propose an alternative primary care delivery model that is consistent with higher quality/lower cost health system research findings and builds on the strengths of the PCMH model, while striving to overcome its implementation challenges.

AN ALTERNATIVE MODEL OF PRIMARY CARE
Care Plus, an alternative to the traditional PCMH model, is defined as a ''patient-centered health care home'' model that includes a wide array of directly provided primary care and support services, coordination by a community health registered nurse (RN) (rather than a physician), and regular RN assessment visits in the patient home.
Broad range of services First, patients have access to a broad range of directly provided services in which the challenges of effective coordination and communication are minimized from the outset. Community-based organizations (such as Community Health Centers) are one such platform that may logically serve as an effective base for this new model of primary care delivery. Consistent with the proposed tenets of the model, this depth and breadth of directly provided services is considerably different from the typical PCMH model and particularly important to an older population who suffer from complex, chronic health conditions. See Table I.
Community health RN as care manager Second, this model positions a community health RN as the care manager, capitalizing on skills inherent in this specialty such as building collaborative partnerships and resource management. The RN Care Manager directs the care, coordinates it, and facilitates the communication among everyone involved. While the PCMH concept places coordination activities with the physician (American College of Physicians, 2005), we believe the skills inherent in ''community health'' nursing -the ability to navigate the system and coordinate services and information for better client outcomes -are precisely the skills needed to improve client outcomes in the complex and fragmented primary health care system that exists today. The RN Care Managers coordinate care for older adult patients while using home environment, family, and community information to develop the individual plan of care.
Ongoing home assessments Finally, in contrast to the PCMH model, Care Plus emphasizes the importance of regularly assessing the patient in his or her own home in order to more fully understand the patient problems and needs and use that information to create an improved patient plan of care. Issues that are especially relevant to the older population including patient safety, functional status, medication issues, nutritional status, and social support are markedly sensitive to assessment in the home. See Table I for model comparisons.
Determining the impact of this model A randomized clinical trial to study the effectiveness of the proposed model of primary care will begin in early 2011. The patient population is expected to have a heavy disease burden with chronic illnesses including diabetes, congestive heart failure, and coronary artery disease, among others. Specific outcomes to be studied include: patient satisfaction, self-rated health, functional status, and cost outcomes including pre-and post-intervention hospitalizations and nursing home stays.

CONCLUDING COMMENTS
Never has innovation, for the purpose of improving health, patient satisfaction, and decreasing cost, been more important. Incorporation of community nursing into primary care delivery may provide the solutions for improving health, satisfaction, and reducing costs.