The Patient-Centered Medical Home

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"

The principal goals of health care reform are to improve quality, increase access, and contain costs. In this issue, Pham and colleagues calculated that a typical primary care clinician must coordi...

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.

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

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

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

Almost 10 years ago, JGIM published a seminal report from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. Boldly titled “The Future of General Internal Medicine”, the report challenged the field of general internal medicine to take responsibility for addressing the “chaos and dysfunction” the Task Force believed characterized medical care at that time. Many of the innovations they proposed, including team based care, enhanced information systems, and the abandonment of the fee-for-service financing model, seemed pie-in-the-sky at the time, but are now accepted by most as essential for improving health care delivery and curbing costs. While much has changed in the past decade, in many ways, general internal medicine still stands at the crossroads. While the options may not be quite so bleak as Woody Allen suggests, general internal medicine continues to face some critical challenges in research, education and clinical practice. In this issue of JGIM, Armstrong et al. (on behalf of the 2012–2013 SGIM Council) articulate these challenges and present a vision for the future of general internal medicine. They point out that the pressure to reduce health care costs and increase value along with the historic passage of the Patient Protection and Affordable Care Act (ACA) will lead to new initiatives in primary care and GIM, featuring population management, team-based care and innovative use of electronic health records. Changes in medical education spurred by duty hours reform and enhanced workforce diversity have resulted in a shift to more training in the ambulatory setting and a shift in focus to measuring competencies rather then medical knowledge. For researchers in academic GIM, they argue that these changes bring both challenges and opportunities. GIM researchers are ideally situated to study the impact of practice transformation and payment reform that will be brought by the Affordable Care Act (ACA), but despite optimism fueled by the Patient Centered Outcomes Research Institute (PCORI), funding challenges will persist. The United States spends almost $3 trillion on health care. According to some analysts, up to 1/3 of these expenditures are wasted on inappropriate, equivocal, misapplied, or inefficient care. If just 1 % of health care payments were applied to scientific evaluation of what works and what doesn’t in health care, a pool of $30 billion would become available to generate answers our country sorely needs. Several articles in this issue of JGIM showcase the value of rigorous empirical research in evaluating innovations in health care practice and policy. The Patient Centered Medical Home (PCMH) has been touted as a solution to the current crisis in primary care, but most evaluations to date have been observational. In two related articles, Fifield, et al. describe the implementation and experimental evaluation of the PCMH model in small-medium sized practices. In their cluster-randomized trial, most practices were successful in achieving NCQA recognition, but there were few consistent differences in processes and outcomes between PCMH and control practices. An accompanying editorial by Landon puts the data in context. The PCMH has implications not just for patients and practitioners but for physicians-in-training. Chang et al. describe a consensus meeting leading to a set of 25 “entrustable professional activities” that residents will be encouraged to perform with varying degrees of independence. Some of the activities are familiar (e.g. “devise a longitudinal care plan for chronic disease”), but others (e.g., “lead an interprofessional health care team”) will require new skills and new curricula to support their development. Workforce development is key to maintaining a robust primary care infrastructure, and medical schools must do their part. Are they contributing in fair measure? An article by Choi and Ayanian suggests not. Research intensive schools produce fewer primary care graduates than their less research-intense counterparts. Lest readers be too quick to judge the Harvards of the world, a Capsule Commentary by Jackson points out that other factors besides medical school orientation (things like salary, prestige, and lifestyle) are likely to be much more important as causes of the primary care workforce crisis. Published online April 12, 2013 JGIM

Providing cancer care: individual or team sport?

The Distributed Medical Home Model, From Video Box to Mailbox

views and personal experiences of people who have especially contributed to the evolution of ideas in the Journal's field of interest.

Patient-Centered Medical Homes May Reduce Emergency Department Use: What Does This Tell Us?

The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive care for children, youth, and adults in the primary care setting. PCMH emphasizes planned care, care coordination, family-centered approaches, and quality of care while also improving access to care and modernizing the care experience. Although health educators as a group have not traditionally focused their efforts on the primary care setting, the PCMH model increases the potential for their inclusion. Health educators, given their training and expertise, are likely to be well positioned to contribute to primary care oriented with a PCMH model. Health educator roles within PCMH that are especially relevant include participating in a team approach to care, attention to coordination and integration of care, and preventive and end-of-life care. Such roles may be realized in direct delivery of patient education such as health coaching, serving as a facilitator or connector to community resources, or involvement in practice or practice organization quality improvement and population-based assessment efforts. If implemented properly, the involvement of health educators in this new model of care has the potential to enhance how primary care is delivered, improve the health of Americans with regard to chronic conditions, and reduce related health care costs.

Over the last 40 years, patient-centered medical home (PCMH) has evolved as the leading primary care practice model, replacing traditional primary care models in the United States and internationally. The goal of PCMH is to improve chronic condition management. In the U.S. Army, the scope of the medical home, which encompasses various care delivery platforms, including PCMH and soldier-centered medical home (SCMH), extends beyond the management of chronic illnesses. These medical home platforms are designed to support the unique health care needs of the U.S. Army's most vital asset-the soldier. The PCMHs and SCMHs within the U.S. Army employ patient-centered care principles while incorporating nationally recognized structural attributes and care processes that work together in a complex adaptive system to improve organizational and patient outcomes. However, U.S. Army policies dictate differences in the structures of PCMHs and SCMHs. Researchers suggest that differences in medical home structures can impact how organizations operationalize care processes, leading to unwanted variance in organizational and patient outcomes. This study aimed to compare 3 care processes (access to care, primary care manager continuity, and patient-centered communication) between PCMHs and SCMHs. This was a retrospective, cross-sectional, and correlational study. We used a subset of data from the Military Data Repository collected between January 1, 2018, and December 31, 2018. The sample included 266 medical home teams providing care for active duty soldiers. Only active duty soldiers were included in the sample. We reviewed current U.S. Army Medical Department policies to describe the structures and operational functioning of PCMHs and SCMHs. General linear mixed regressions were used to evaluate the associations between medical home type and outcome measures. The U.S. Army Medical Department Center and School Institutional Review Board approved this study. There was no significant difference in access to 24-hour and future appointments or soldiers' perception of access between PCMHs and SCMHs. There was no significant difference in primary care manager continuity. There was a significant difference in medical home team continuity (P < .001), with SCMHs performing better. There was no significant difference in patient-centered communication scores. Our analysis showed that while the PCMH and SCMH models were designed to improve primary care manager continuity, access to care, and communication, medical home teams within the U.S. Army are not consistently meeting the Military Health System standard of care benchmarks for these care processes. Our findings comparing 3 critical medical home care processes suggest that structural differences may impact continuity but not access to care or communication. There is an opportunity to further explore and improve access to appointments within 24 hours, primary care manager and medical home team continuity, perception of access to care, and the quality of patient-centered communication among soldiers. Knowledge gained from this study is essential to soldier medical readiness.

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.