Primary Care: Too Important to Fail

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

In North Carolina, ∼5% or 57 000 children enrolled in Medicaid have complex medical conditions and account for >50% of the Medicaid dollars spent each year on the medical care of children. In 2012, Community Care of North Carolina (CCNC) received a Center for Medicare and Medicaid Innovations grant to establish the North Carolina Child Health Accountable Care Collaborative (CHACC) to address the health care needs of these children. Care coordination is an integral part of health reform activities, including many Medicare programs. CHACC appears to use a unique approach of targeting higher-cost pediatric Medicaid patients and placing specialty care managers in tertiary children's services.1,2 CCNC serves North Carolina Medicaid beneficiaries through a statewide, community-based public–private partnership, providing care through medical homes using population management approaches to improve care and contain costs.3 CHACC encourages medical and other health professionals to improve quality and cost-effectiveness of care for children on Medicaid with complex medical conditions. A primary goal of CHACC is to ensure that every child with a complex illness has a medical home in the community where he or she lives and receives coordinated primary and subspecialty care to reduce care fragmentation and cost. One target is reduction of unnecessary emergency department visits and hospitalizations. Although hospital revenues will be affected, hospitals will be better positioned to compete in the value-based care environment.4 CHACC patients are all North Carolina Medicaid beneficiaries enrolled in CCNC for care, allowing seamless identification and clinical information exchange by CHACC staff who are CCNC employees.Historically, CCNC has focused on primary care; however, CHACC bridges subspecialty and hospital-based care at 13 North Carolina hospitals with tertiary children's services with embedded care coordinators. The care coordinators are nurses or social workers with pediatric clinical experience. Their activities include completion of a comprehensive assessment of patient and family needs, care plan development, referrals to community services, patient and caretaker education, and collaboration with providers and caregivers to facilitate transitions in care. They provide a "warm handoff" to the community-based CCNC care coordinators in primary care practices and serve as dedicated links between the subspecialist team and primary care professionals. Care plans for these children are posted on a secure CCNC web-based provider portal, giving primary care professionals a centralized site to review and download care plans and to communicate with the community-based and tertiary care coordinators and subspecialists. The care plans have been well received by the community-based physicians caring for these children, reducing the communication burden of caretakers as intermediaries. A family satisfaction survey is being used to gain insight into caretaker perspectives. As one of the participating pediatric surgeons said, "This [CHACC program] is what I have been waiting for. With the care plan, I had everything I needed to care for the child in front of me. It is better than our brand new EHR!"Identifying the target population for CHACC enrollment is a continuing challenge. Nationally accepted tools for predictive models to identify children with complex medical conditions whose care may be "impactable" (quality improvement and cost reduction) have not been developed. To address this gap, North Carolina Medicaid claim data were used to help identify patient populations who may benefit from the program. In parallel, claim data for CHACC-enrolled children are being collected to determine impact on Medicaid costs, initially comparing CHACC patients with historical groups of similar patients. Advanced analytics are being developed to create predictive models to identify "impactable" patients early in their course, providing the opportunity for care managers to improve quality of care, comanagement, and cost reduction. To date, >1500 patients have been enrolled in CHACC in the first 6 months of the program. Collaborative learning is a key part of CHACC. At the 5 academic centers, work is under way to develop approaches for transitioning care to medical homes in the community using comanagement partnerships with subspecialists. For example, in a 29-county area of eastern North Carolina, the Department of Pediatrics at East Carolina University established the Center for Children with Complex and Chronic Conditions (C5) in 2008. From 2008 to 2010, C5 enrolled 234 children with complex conditions (eg, tracheostomies, gastrostomy tubes, ventilators, feeding pumps, cerebral palsy, intellectual disabilities, complex genetic syndromes) and began coordinating inpatient and outpatient care of these children. CHACC is aiding C5 with additional care managers and new communication links with primary care physicians. So far, C5 staff have documented a 20% reduction in average inpatient length of stay for ventilator-dependent patients, a 36% reduction in readmissions during the first month after discharge, a 26% reduction in readmissions during the first year after initial discharge, a 55% reduction in overall rehospitalizations, and an 11% reduction in emergency department visits. The calculated savings total for 2008 to 2010 is >$6 million.5 To continue this program, care coordination is necessary to support these children in the community. Also, residents, primary care physicians, and parents need more education about the patient's care.To address issues of access to subspecialists across North Carolina, CHACC is developing concise guidelines to aid primary care providers in the care of children with common pediatric conditions often referred prematurely or unnecessarily to pediatric subspecialists. CHACC guidelines are developed in joint day-long work groups of pediatric subspecialists from North Carolina academic medical centers and community primary care physicians. The work group reviews evidence-based data, published guidelines, and, where conclusive data are not available, consensus of subspecialists and primary care physicians on guideline content. A subgroup writes a draft guideline, sharing it for review with subspecialists and generalists across the state. The final guideline is published on the CCNC Web site (https://www.communitycarenc.org/emerging-initiatives/child-health-accountable-care-collaborative/chacc-gi/). Guidelines include consensus recommendations for appropriate primary care clinical evaluation, including laboratory, imaging, management guidance, "red flag" guidelines for immediate referral, and patient and family educational material. Final guidelines include endorsement from the subspecialty groups at all 5 North Carolina academic medical centers. The CHACC steering committee works with the North Carolina chapter of the American Academy of Pediatrics and the CCNC networks across the state to educate primary care health professionals about the guidelines and to encourage their use. Guidelines for constipation, gastroesophageal reflux, and chronic abdominal pain are available, and a guideline for headaches is in draft review.Informal feedback from primary care providers describes the guidelines as easy to download in a busy primary care practice and useful for patient care and family education. It is expected that this tool will aid in convincing families and patients to continue care in the primary care setting unless patients manifest "red flag" symptoms or meet referral guidelines. More formal evaluation of the impact of these guidelines on subspecialty access is under way.CHACC appears to create a unique, care management–based, statewide engagement of pediatric subspecialists and general pediatricians and primary care providers for developing comanagement protocols for children with complex conditions and promoting coordinated, efficient, high-quality, and cost-effective care. As medical providers in North Carolina engage in payment reform transition, including risk-based contracting, CHACC provides a platform to evaluate high-cost medical care for children. We anticipate that the cost savings from CHACC will be useful in justifying continuation of the program after completion of the grant-funded work and will be a stepping stone to value-based care for children in North Carolina Medicaid and adults with high-cost chronic illness moving between levels of care.Our work leads us to call for more development of tools for predictive analysis and risk adjustment for medically complex children, and we are pleased to see others working in this area.6 More work is needed in subspecialty referral management using tools such as the CHACC guidelines. We believe the medically complex child and the structure of the health care delivery system for these children reinforces the old saying, "Children are not just little adults."7Elizabeth Cuervo Tilson, MD, carried out the initial review of the manuscript and provided revisions to the original document.

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Registered nurses in primary care: A value proposition

Report of the AACP Task Force on Patient-Centered Medical Homes and Accountable Care Organizations

With the increasing use of technology in health care, providers must be aware of their patients' proficiency and preferences for the use of such resources.1 Although some studies have suggested the potential effects of technology on patient–physician relationships in specialists' offices, there is scant evidence on its use and patient preferences in the primary care setting.2-5 It is important to understand how best to use available technologies within the medical system. Provider awareness of patient abilities and preferences, along with better patient access to healthcare information, leads to overall better health outcomes,6-10 yet more information is needed before it will be possible to develop an advanced medical system that successfully integrates current technologies with the concept of a patient-centered medical home. A survey was designed to determine what forms of technology people currently use and what health information technology they prefer to use for future communication. Individuals who presented for primary care office visits were surveyed. The survey consisted of an anonymous two-page questionnaire. The first page assessed the participant's age, sex, and current use of various technologies (e.g., cell phone, internet, social networking). The second page surveyed interest in using these technologies in a variety of settings (scheduling appointments, asking for refills, accessing personal medical information). Five hundred thirty-four people completed the surveys, including 130 who were older, 240 middle aged, and 164 younger. In terms of current use of technology, older adults used every surveyed technology significantly less than middle-aged and younger adults, although the majority of older adults indicated that they used internet, e-mail, and cellular telephones (50%, 54%, and 75%, respectively). When communicating with their primary care office, older adults indicated a preference for landline telephone use (Figure 1). Finally, when asked to indicate how they would use these technologies, no significant differences were seen between the age groups. As had been hypothesized, older adults not only differed from younger adults in their current use of technology, but they also preferred different ways to interact with their doctor's office. For each modern technological modality surveyed, older adults were less likely to use it than younger adults. Understandably then, older adults were more hesitant to accept some of these modalities as a means to communicate with their primary care physicians than the more technologically savvy younger adults. Although less technologically capable than younger populations, the majority of older adults indicated that they used cellular telephones, the internet, and e-mail. Perhaps because they learned these modalities later in life, older adults do not feel comfortable using them to contact their doctor; younger adults who grew up with these technologies are more likely to trust them with their medical information. When asked how they would use the surveyed technologies, the different age groups responded similarly. The only service that each group chose against was access to their medical chart, which signals that, although older adults may feel more comfortable with traditional means of communication, to some degree, everyone is skeptical of their primary care offices overstepping boundaries with regard to technology. As providers begin to develop the concept of the patient-centered medical home, it is important to keep their patients' wishes in mind. If older adults still prefer a traditional means of communicating with their primary care doctors, perhaps practices with older-adult populations should dedicate more resources to perfecting landline communication with their patients. Practices with younger populations would probably experience an easier transition into a technologically advanced medical home and may consider investing in e-mail or internet services. Finally, the survey exemplified willingness to participate in the discussion of an advanced medical home. Hundreds of surveys were collected in a short period of time by simply asking people for their preferences. It is a step that primary care practices should include in the process of transforming the medical home. Conflict of Interest: MS is sponsored in kind under an unrelated Health Resources and Services Administration grant and through an American Academy of Family Physicians stipend provided for salary support to the Department of Family and Community Medicine for participation in their Vaccine Science Fellowship. MS is a board member for the Southeast Pennsylvania Health Education Council and the Delaware Academy of Family Physicians. All resources were available through Christiana Care Health System without funding. Author Contributions: Weinberg, Guarino, Savoy, Horton, and Reed: study concept, study design, acquisition of subjects, data interpretation, and manuscript preparation. Reed: data analysis. Sponsor's Role: None.

Providing cancer care: individual or team sport?

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

Behavioral Health Data in the Electronic Health Record: Privacy Concerns Slow Sharing

During the past several decades, population aging and chronic diseases have been common burdens to nearly all the world's countries. To meet future health care needs, many countries have tried to improve the efficiency and equity of the health care system by reforming primary care. In the UK, which has already achieved a high level of strength in primary care, the Quality and Outcomes Framework (2004) was introduced and a great deal of the National Health Service (NHS) budget has been invested in primary care. In the US, a country with a low level of strength in primary care, to transform primary care practices to model practices, medical home movements such as the Patient-Centered Medical Home (PCMH) have been initiated after the development of the joint principles of the PCMH (2007) by 4 major societies of primary care. In Australia, despite having achieved high levels of health outcomes among the OECD countries, the Practice Incentives Program (PIP) has been introduced to respond to concerns about quality and coordination of care and prevention in 1998. In South Korea, a country with a very weak infrastructure in primary health care, where primary care has never been explicitly defined at the national level, the government is trying to improve quality in chronic care by using small financial incentives. The authors assert that a standard model and a quality appraisal framework for the organization of primary care are necessary to achieve the goals of primary care reform in this country.

The passage of the Patient Protection and Affordable Care Act (ACA) of 2010 has helped reshape primary care by funding the development of care approaches that better integrate and coordinate services, such as the patient-centered medical home (PCMH). Primary care practices that adopt this model offer the comprehensive, patient-centered care that is especially needed by those who are chronically ill. In a significant change from traditional reimbursement policies, the ACA offers incentives and resources that allow for care coordinators-who are typically nurses-to be recognized and paid for their efforts.This article discusses the guiding principles of the PCMH model, nurse care coordination, reimbursement and implementation, cost-effectiveness and quality improvement, and the need for greater nurse advocacy. Finally, the experience of a care coordinator in a rural PCMH in Maine is presented.

Last December, the Chronic Care Working Group (CCWG), a bipartisan collaboration of Senate Finance Committee members chaired by Senators Isakson (R-GA) and Warner (D-VA), released its policy options document.1 The CCWG had a formidable charge—to “analyze current law, discuss alternative policy options, and develop bipartisan legislative solutions” that increased care coordination across settings, streamlined Medicare payment while aligning incentives, facilitated high-quality care, produced better outcomes, and reduced growth in Medicare spending. The requirement that proposals be budget neutral or cost saving narrowed the choices. After reviewing more than 530 comments, the CCWG met with 80 stakeholder groups, ultimately recommending 24 options, including two that focused on improving the infrastructure of chronic care with better quality measures and more-accurate measures of cost for payment and computing shared savings. Of the proposals, 16 were for enhanced chronic care, with 11 focused on capitated payments (e.g., Medicare Advantage (MA)) or shared savings (accountable care organizations (ACOs), Independence at Home (IAH)) (Table 1). Despite government efforts to promote systems of care that feature cost containment strategies such as capitation (MA) or shared savings (ACOs), more than half of the 49 million Medicare beneficiaries continue to receive care from fee-for-service (Medicare A and B) providers, without spending constraints. Proposals to enhance care within traditional fee-for-service (FFS) Medicare were limited to new billing codes for high-intensity chronic care management, counseling regarding prognosis of serious illnesses, and limiting constraints on telemedicine for specific patient groups. There is wide recognition that Medicare spending is concentrated in beneficiaries with advanced chronic illness.2 Nearly half of FFS spending is for 5% of beneficiaries, the 1.7 million with annual spending exceeding $54,000 per person, compared with $9,900 for the average Medicare beneficiary. Recognizing where spending is concentrated is necessary but is only the first step toward creating targeted policy to advance high-quality care and reduce costs. Of the 34 demonstrations that CMS formally evaluated over the past 15 years,3 only two were substantially successful in reducing costs and increasing quality.4, 5 The main lessons from these demonstrations are not surprising. There is value in targeting high-cost beneficiaries and developing trusting human relationships where engaged patients and providers work toward common goals; there is significantly less cost savings and quality improvement in efforts where providers work by themselves, focus work on telephonic management, are disconnected from primary care, or focus merely on technology-assisted data acquisition and algorithm-driven care plans.4 Two notably successful FFS programs—Health Quality Partners and Massachusetts General Hospital (MGH)—relied on administrative fees to pay for provider time and additional personnel needed for managing complex patients. Both programs relied on engagement between care managers, patients, and providers; the MGH model embedded care managers in primary care practices. In contrast, patient-centered medical homes, despite a similar conceptual design, have had an uneven record in controlling costs, in part because of a less-targeted focus.6, 7 Several of CCWG's proposals favor expanding MA plan options and converting special needs plans (SNPs) to permanent status. These managed care organizations receive risk-adjusted capitation for each beneficiary, providing a strong incentive to actively manage their chronically ill members. A few provider–insurer organizations have proven effective at managing some of Medicare's frailest beneficiaries under capitation. Programs of All-inclusive Care for the Elderly (PACE), which typically operates small programs for 100 to 1,200 enrollees, now covering 34,000 frail elderly adults eligible for nursing facility care, and the Commonwealth Care Alliance dually eligible managed care organization (MCO) in Massachusetts are strong examples of effective care under a capitation model.8, 9 Although these organizations receive a risk-adjusted, capitated payment, the important feature is that providers and patients develop and manage the care plan in small groups. Another approach that has shown promise for these populations are Medicare shared savings programs (MSSPs), such as ACOs, which are also strongly incentivized, with rewards contingent on improving upon a risk-adjusted baseline cost target for assigned beneficiaries. CMS' evaluation of ACOs suggested that they saved $424 per beneficiary in their first year and $257 per beneficiary over 2 years.10 Several CCWG recommendations seek to make ACOs and other shared savings plans more accountable (e.g., by allowing prospective attribution by patients) and more flexible (e.g., broadening options to include nonmedical support services and relieving restrictions, such as the homebound status requirement for home health care.) The CCWG logic is clear—with a budget constraint, fewer of the rules to control overuse observed under FFS payment are needed, rules which may have perverse effects on outcomes and costs. Topping the CCWG's list of options is Independence at Home (IAH), a 3-year demonstration (2012–15) that Congress unanimously extended for 2 years in June 2015.11 The favorable initial published results are consistent with those of the successful Department of Veterans Affairs national Home Based Primary Care (HBPC) program12 and other published HBPC models.13-15 IAH rests on three precepts: focus on the most frail, immobile, and costly beneficiaries; use mobile interdisciplinary provider teams led by physicians and nurse practitioners responsible for their care and accountable across the health spectrum; and align incentives. IAH's novel approach to “shared savings with discipline” uses eligibility criteria identifiable in CMS administrative data,1 so that the savings baseline can be accurately calibrated. It allocates the first 5% of savings to CMS, after which there is an opportunity for shared savings, and IAH disqualifies practices that fail to achieve savings or to meet three of six quality metrics after 2 years. CMS found that IAH practices saved more than $25 million during the first performance year—an average of $3,070 per beneficiary—while delivering high-quality care. With 8,400 frail elderly adults enrolled, Year 1 savings were 7.7%, with nine of 17 (53%) practices achieving the 5% savings threshold (range $2,676–13,068/patient-year). For those nine practices, the average savings rate was 17%, with the top-performing practice reducing costs by 32%. Successful practices were broadly representative, coming from medium and large academic centers, and private for-profit and nonprofit corporate and community practices. Although IAH programs managed fewer than 1% of the number of individuals in the original 32 ACOs (Pioneer ACOs), IAH generated nearly 9% of the combined first year CMS savings of Pioneer ACOs and IAH.10 Unlike the two-sided risk in the Pioneer ACO model, in IAH, discipline comes from being disqualified and thus unable to share in substantial achievable savings. Using the 2012 Medicare 5% beneficiary file, it was estimated that 2.2 million Medicare beneficiaries meet IAH criteria,1 6.2% of all FFS beneficiaries, with 40% of the 5% most-expensive beneficiaries in 2012. Of all Medicare FFS beneficiaries, these individuals represented 23% of the deaths, 43% of Medicare readmissions, 37% of new long-term institutional stays, and 28% of FFS spending, validating the targeting criteria. Over the next decade, if home-based primary care through IAH reached only 35% of this population, maintaining the first year demonstration experience, it is likely that it would generate savings exceeding $35 billion, with CMS retaining more than $17 billion,16 which is within 3% of the estimated savings from applying VA's HBPC experience to 35% of the IAH-eligible Medicare population. The congruence of effectiveness between VA's national program and the CMS demonstration gives support to the estimate. Two of the CCWG's recommendations are crucial for cost containment in FFS Medicare, applicable to ACOs and IAH: developing more-accurate risk adjustment models for the highest-cost beneficiaries and developing appropriate quality metrics, with a focus on patient experience. The current system of risk assessment for ACOs relies on hierarchical condition categories (HCCs) to develop cost benchmarks.17 Analyses of beneficiaries similar to those qualified for IAH18 have confirmed other reports19 that current HCC models, calibrated on the entire Medicare population, substantially underpredict costs for a selected population, with mortality four times as great, costs five times as high, and more than half of beneficiaries joining a practice being clinically unstable at enrollment. HCC predicted costs also have wide geographic variation whereas frail beneficiaries are more similar cost-wise between low- and high-cost counties. In PACE, a combination of PACE rates, the PACE HCC model, and PACE frailty adjusters have effectively addressed these phenomena.8, 14 Similar recalibration of the HCC model to account for mortality risk, frailty, and local variability among individuals meeting IAH qualifying criteria is needed while incorporating a time-dependent clinical instability factor.18 Quality metrics offer a balancing force for shared savings incentives. In contrast to the large suite of measures for ACOs, the IAH demonstration used six quality measures to moderate savings shares: soliciting patient preferences; improving care transitions through home visits within 48 hours; including medication reconciliation after a hospitalization or emergency department visit; and validated, care-sensitive usage metrics (30-day readmissions, ambulatory care–sensitive hospitalizations, and emergency department visits). The National Home-Based Primary and Palliative Care Network is field testing additional metrics, particularly ones focused on patient and caregiver experiences.20 Effective, efficient chronic illness management requires making decisions about goals and value. The potential for shared savings to provide the needed constraint in FFS Medicare should foster the transition from volume to value while keeping the provider–patient relationship at the center, giving people care that they want and need. The CCWG's lead option, converting IAH to a Medicare benefit, will advance that transition, achieving the CCWG's goals of coordinating care across sites, aligning incentives, and improving outcomes while lowering costs. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Drs. Kinosian, Taler, and Boling are participants in the IAH Demonstration, as are the other 14 members of the IAH Learning Collaborative Writing Group. Drs. Kinosian, Taler, and Boling have provided testimony to CMS and the Senate Finance Committee's Chronic Care Working Group, as well as MedPAC, on the Independence at Home demonstration. Dr. Kinosian is a board member of the American Academy of Home Care Medicine; Drs. Taler and Boling are past board members. Author Contributions: Kinosian: design, analysis, manuscript preparation. Boling, Taler: design, manuscript preparation. Sponsor's Role: NA.

The contributions of primary care to improvements in many aspects of population and individual health are well documented (Starfield, Shi, and Macinko 2005). In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population subgroups. The findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs. Studies within countries, including both industrialized as well as middle income and developing countries, are consistent in showing greater improvements in health consequent to legislative and administrative policy initiatives directed at strengthening primary care, including increases in the supply and use of primary care practitioners and clinical improvements in primary care practice. The special and critical features of primary care are well known and include first contact access and use of primary care facilities and practitioners; person-focused (not disease-focused) care over time; comprehensiveness of services available and provided within primary care; and coordination of services when they are needed elsewhere (Starfield, Shi, and Macinko 2005).

Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.