Welcome to Value-Based Care Healthcare Delivery. This is lecture D, The Patient-Centered Medical Home. This lecture is an overview of issues related to the implementation and effectiveness of the Patient-Centered Medical Home in the United States healthcare delivery system. The objectives for this lecture, The Patient-Centered Medical Home, are to first, describe the origins of the Patient-Centered Medical Home and provide a definition. Second, discuss issues related to the adoption and implementation of the Patient-Centered Medical Home. And third, based on current research, discuss the effects of the Patient-Centered Medical Home on cost, quality, access, and experience outcomes. The Patient-Centered Medical Home concept, known as the PCMH or medical home, originated in 1967 in the pediatric population, but did not gain much traction at that time. It was revived in the early 2000s in response to concerns about rising healthcare costs, poor quality of care, and the ability of the existing primary care system to meet these challenges. For many healthcare experts, given its ambitious goal of comprehensively transforming the primary care delivery system, the Patient-Centered Medical Home is seen as a means of achieving the Triple Aim, that is, improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care for populations. Most current versions of the Patient-Centered Medical Home are extensions of the Chronic Care Model developed by Ed Wagner of the Group Health Cooperative of Puget Sound, which emphasizes patient self-management of their chronic disease and team-based care that draws upon a diverse group of healthcare professionals. The Patient-Centered Medical Home definition adopted and discussed throughout this presentation is that as Stange and colleagues described, it is a comprehensive, team-based approach to providing care that aims to personalize, prioritize, and integrate care, to improve the health of individuals, families and populations of people. Most Patient-Centered Medical Home definitions and initiatives are roughly organized around seven principles promulgated by the Patient-Centered Primary Care Collaborative, or PCPCC. Having a personal physician, pertains to continuity and refers to the idea that patients have a continuous care relationship over time with their physician. Physician directed medical practice refers to team-based care that incorporates the knowledge and skills of different professional disciplines. Whole person orientation related to comprehensiveness of care. And, the idea that the medical practice can assume responsibility for most, if not all, of a patient's healthcare needs. Care coordination refers to integration across care settings. There needs to be communication across transitions of care, such as transferring from the ambulatory setting to the hospital, or the hospital to a rehabilitation setting. Health information technology can play an important role in enabling effective communication and exchange of health information. Quality and safety refers to whether a practice has structures and processes in place that promote quality and safety. Health information technology, such as electronic health records, e-prescribing, and clinical decision support, as well as dashboards, can be used to promote and monitor quality and safety. Enhanced access refers to whether patients have timely access to care. Scheduling systems or patient portals, which allow patients to message their physicians or schedule their appointments, can facilitate access to care. Finally, payment relates to the idea that a payment system is in place to initiate and sustain the first six principles. This may include rewarding practices for reducing hospitalizations and other improvements in quality and safety, and recognizing that there may be additional time and cost needed to implement and support the first six principles. There has been rapid growth in the number of organizations sponsoring PCMH programs. Because of this rapid growth, accurate figures are somewhat difficult to come by. But as of the end of 2012, 41 state Medicaid programs were pursuing some kind of PCMH initiative. In addition, a number of federal agencies such as the Centers for Medicare and Medicaid Services or CMS, AHRQ or "arc" which is the agency for healthcare research and quality, the VA, and HRSA or "hersa," the Health Resources and Services Administration, have been exploring demonstration programs that relate to or include some aspects of the PCMH. For example, the State Innovation Models Initiative, know as SIM, which is sponsored by CMS, provides financial and technical support to states to develop and test payment and delivery system models that can improve health system performance many of which include implementing the Patient-Centered Medical Home. The number of private sector organizations sponsoring PCMH programs is even greater still with a number of programs numbering in the 100s and still growing. A list of PCMH programs, public and private, is maintained by the Patient-Centered Primary Care Collaborative. Given the growth in the number of programs, a number of accrediting organizations have emerged to certify providers as Patient-Centered Medical Homes. Some of the major accrediting bodies include the National Committee for Quality Assurance, the Joint Commission, and the Accreditation Association for Ambulatory HealthCare. According to the criteria, outlined in the Medicare Access and CHIP Reauthorization Act known as MACRA, some Patient-Centered Medical Homes may qualify as Alternative Payment Models also known as APMs. The purpose of these Alternatives Payments Models is to use new financial models to reward providers for focusing on quality and value. To qualify as an APM, the APM must meet three requirements. First, they must require participants to use certified electronic health records. Second, they must base payment on quality measures. And third, they must require participants to accept financial risk. For financial losses providers may also qualify as an APM, if they function as a medical home authorized by the Center for Medicare and Medicaid Innovation, known as CMMI. It remains to be determined however, how CMS will treat providers certified as PCMHs from other programs such as state Medicaid agencies and private payers. Given the growth in a number of PCMH programs and the emergence of multiple accrediting agencies, considerable variation exists with respect to what constitutes a Patient-Centered Medical Home. A review by the Urban Institute found that most programs emphasize five domains or capabilities. Care coordination, health information technology, quality measurement, patient engagement, and self management, and presence of policies In general, evaluations of the Patient-Centered Medical Home have found that providers have struggled to implement many activities associated with the Patient-Centered Medical Home. One study in 2013 for example, estimated that physician practices had implemented approximately 37% of the total capabilities measured by the National Committee on Quality Assurance. Other resources found however, the practices vary in their implementation success. Larger organizations in general have been more successful at implementing different activities associated with the Patient-Centered Medical Home. This is because larger organizations typically have more resources to devote to implementing the Patient-Centered Medical Home. And they are able to commit these resources over sustained periods of time. Regardless of size, organizations have struggled with more implementing activities related to health information technology. Such as an electronic health record or EHR, disease registry or patient portal, compared to direct patient care activities. Such as engaging in shared decision-making, or coordinating care with other organizations. Many of the issues with technology arise not just in the implementation of a particular technology. But in engaging with other stakeholders who may not be as comfortable with the technology. For instance, a patient portal can facilitate communication. But many patients need encouragement and training to use it. Similarly, while the number of organizations who have implemented an EHR has increased in recent years, there are still many settings where adoption of EHRs is low. These include long-term care settings and some specialties, which make electronic exchange of information difficult. Evaluations have identified a number of common challenges that providers face when trying to implement the Patient-Centered Medical Home. And why levels of implementation are so modest. The first challenge relates to the fact that implementing the Patient-Centered Medical Home represents a fundamental transformation of what the practice is and does. One that replaces old patterns and processes with new ones. Such transformation may include new scheduling and access arrangements. New coordinations with other parts of the healthcare system, group visits, novel ways of bringing evidence to the point of care, quality improvement activities and utilizing more point of care services. Other challenges include developing teamed-based care practices, changes and practice management, new strategies for patient engagement and multiple new uses of information technology. To make things more complicated, these changes are typically highly interdependent. Where changes made in one process or part of the organization have ripple effects on other parts of the organization. The second challenge pertains to information technology. Most Patient-Centered Medical Home programs require or strongly encourage the use of an electronic health record to facilitate coordination and continuity of care across time and setting. However, having an electronic health record may not be sufficient to allow providers to engage in the types of transformational activities required. For example, not all electronic medical records contain functionalities such as electronic prescribing or patient portals. Although the meaningful use requirements are bringing more uniformity in these functions. Another issue with the technology is that PCMH requires coordination among different health care providers. Since these providers are likely to use systems from different vendors, interoperability or the ability for systems to communicate with one another can be problematic. If the same standards are not used across systems, which is often the case. Now that more practices are using electronic health records, there is growing recognition of the need to harmonize the various standards and efforts. And the Office of the National Coordinator has developed an interoperability road map to guide the needed activities. Furthermore, when provider organizations have attempted to implement different health information technologies. The experience is generally one where the implementation was more difficult and time-consuming than originally expected. Implementation of health IT requires attention to the technical and the people issues. There are best practices for implementation of health IT that include thorough planning, good change management, adequate training, and other means of engaging the providers who will have to use the new technology. Unfortunately, these practices are not always followed, resulting in delays and frustration. The third challenge relates to the fact that becoming a Patient-Centered Medical Home often requires clinicians and patients to change their perspectives. For clinicians, this may include things such as adopting a team based orientation, whereas they may be accustomed to acting independently. Likewise, as a Patient-Centered Medical Home, clinicians are expected to adopt a population health perspective that emphasizes proactive preventive care. Whereas they may have originally been trained to focus on one patient at a time. Patients may similarly struggle with adopting a different perspective. Because the Patient-Centered Medical Home emphasizes shared decision making with the patient at the center of the team. Patients are expected to take a more proactive role during exchanges with their healthcare providers, as well as outside of the office. This can often diverge from traditional interactions with the healthcare system. Given all of the changes that take place, one of the other challenges to implementing the Patient-Centered Medical Home is change fatigue, stress, burnout, and turnover are very real treat to practices undertaking such dramatic transformation. Especially, if it is occurring within a short period of time. Such concern need to be closely attended to. If the practice is to make and sustain progress toward becoming a patient centered medical home. Based on the previous challenges, experts have made a number of recommendations to help practitioners interested in adopting and implementing the patient centered medical home. First, experts recommend that practitioners interested in becoming a patient centered medical home begin the process with their eyes wide open. Understanding that the transformation will be a lengthy process and will require significant time, effort, and financial resources. And above all, persistence. The adoption and implementation of health information technology in particular is a challenging element of PCMH transformation because it requires a significant investment of financial resources and entails working closely with external vendors. Consequently practices may feel they have less control over this part of the process and its consequences. More generally the transformation process will also entail wide scale changes throughout the practice. So, everyone needs to be ready and willing to engage in the change process. Disruptions to care processes and routines may even lead to a decline in results in the short term. In general, experts have emphasized a number of specific technology functionalities that are believed to be central to promoting better quality outcomes than a patient centered medical home. These include clinical decision support to improve diagnostic and treatment decision-making. Registries to more effectively manage populations patients, especially those with chronic conditions. Personal health records to help patients engage more fully in their care. And telehealth technologies to support self management of care and improve access to care, especially in rural areas. However, experts have also advised practices that, given the time and financial investment for implementing health information technology, they should develop a plan that fits their unique circumstances. One size fits all recommendations should be viewed skeptically and practitioners should expect their plans and experiences to address their specific needs and resources capabilities. Furthermore, given the rapid pace of change in health information technology, practitioners should revisit this plan regularly and expect modifications to be necessary. Given the extent of change required and the length of time required to implement the patient centered medical home, leaders of organizations implementing the patients centered medical home should pay attention to the burdens it is placing on staff and colleagues. Drastic changes that require extended periods of time to implement, especially without a clear understanding of the means end relationship, can result in staff and colleagues reverting back to old patterns, routines, and technologies. It is important to make sure that staff understand the goals. And that they understand the commitment that's need. Finally, members of organizations implementing the patients centered medical home should embrace learning as the norm. Because of the length of time required to implement the patient centered medical home, and the interdependencies among the different changes that must occur, it is likely that new problems will emerge. Not all of which can be predicted or easily solved. Developing an appreciation for how previous solutions and experiences can be applied to new problems is essential for moving forward on the patient-centered medical home journey and sustaining the gains that have been made. Despite the challenges associated with implementing the patient-centered medical home or perhaps because of them there is great interest in knowing whether it can produce better quality, lower costs and improve access to care and the overall patient experience. Consequently empirical research related to health and fiscal outcomes is one of the fastest growing areas of health services research. To date, the empirical evidence guarding the effects of the patient centered medical home are mixed. Depending on the type of outcome one is considering. The most consistent evidence relates to quality, where research has shown patient centered medical home is generally associated with better quality. For example several recent reviews of the patient centered medial home literature have concluded that the patient centered medical home is associated delivery of preventative care services and few emergency department visits. In contrast, relatively little research has examined whether the patient-centered medical home is associated with lower costs or better access. What little research does exist has found mixed results, with some studies showing the patient-centered medical home Is associated with lower cost and other studies showing no affect on costs. The same is true for access. The research related to the patient and staffing experience is also mixed. Research and reviews have generally shown that patient center medical home implementation, Is not associated with better patient experience, however it can reduce feelings of burnout among healthcare professionals working in these environments. This concludes Lecture d of Healthcare Delivery. To summarize, there has been a proliferation of patient centered medical owned programs since their revival approximately 15 years ago. This proliferation has resulted in a variety of different programs. Each typically with their own unique expectations and challenges. Regardless of the program most organizations have faced a wide range of challenges when attempting to implement the patient centered medical home. While there have been many lessons learned from these experiences, most experts agree that there is some degree of customization required to effectively implement and sustain the patient centered medical home. Finally, research to date has shown the patient-centered medical home has had some success at improving outcomes, but its success is not universal and is limited to certain types of outcomes. In particular, the patient-centered medical home seems to improve quality of care, while the jury is still out on its effect on cost, access and patient experience.
