The patient-centered medical home concept has been around since 1967, when it was first introduced by the American Academy of Pediatrics. More than 40 years later, widespread implementation has yet to occur, but the health reform law and the "meaningful use" incentives have given the concept new legs.
The patient-centered medical home model aims to improve consumer access to primary care services and increase care coordination. Advocates say such a team-based care model can reduce costs, prevent unnecessary hospitalizations and improve population-based health.
According to Paul Keckley, executive director of the Deloitte Center for Health Solutions, the patient-centered medical home "is an advancement in the design, delivery and payment for health care services that leverages emergent characteristics of a transformed health system -- shared decision-making with patients, multidisciplinary teams where all participate actively in the continuum of care, incentives for adherence to evidence-based practices and cost efficiency, and health information technologies that equip members of the care team and consumers to make appropriate decisions and monitor results."
Where Does Health IT Fit In?
Advocates of the patient-centered medical home model say health IT implementation is critical. Health IT -- such as electronic health record systems, disease registries, personal health records, clinical decision support and Web-based services -- can allow clinicians to access and share key patient information across the stages of care, increase patient access to care, support physician-patient communication and allow for more timely and accurate care.
Paul Grundy -- director of Healthcare, Technology and Strategic Initiatives for IBM Global Wellbeing Services and Health Benefits and president of the Patient-Centered Primary Care Collaborative's board of directors -- said, "You would really find it hard to have a medical home without data, without [health] IT, without actionable information, unless you did it on a small scale." He added, "Health information technology does to the doctors' brains what X-ray has done to their vision."
While experts say health IT holds great promise for the medical home model, EHR adoption still is relatively low -- only 6.3% of physicians used a "fully functional" EHR system in 2009 -- and currently available systems do not necessarily perform all the functions necessary for a patient-centered medical home.
Grundy said, "A lot of the stuff out there now is extremely primitive." He added, "Most of the current systems that are out there now -- the [EHRs] -- really come out of practice management. They're really about collecting money, and not about doing real patient management." He also noted that a lot of systems are "very hard to use."
In a September Health Affairs article, David Bates and Asaf Bitton of Brigham and Women's Hospital in Boston argue that most EHRs "today need further development of features that patient-centered medical homes require to improve their efficiency, quality, and safety."
Bates and Bitton say that to fully support the medical home, EHRs must include seven domains of functionality:
- Clinical decision support;
- Registries;
- Team care;
- Care transitions;
- PHRs;
- Telehealth; and
- Measurement and performance reporting.
Grundy predicted that health IT systems will improve. He said, "There's going to be a lot of transformation over the next few years, and there's gazillions of dollars going into that transformation."
Medical Home and Health Reform
While not as publicized as other provisions of the health reform law, the Patient Protection and Affordable Care Act of 2010 includes multiple references to the patient-centered medical home.
For example, the reform law includes funding for several medical home demonstration projects. The Center for Medicare and Medicaid Innovation, created by the health reform law, is tasked with testing and evaluating payment and service delivery models, including medical homes, as a way to reduce unnecessary spending and preserve or improve care quality. The overhaul also gives the HHS secretary the authority to expand the use of patient-centered medical homes or other care delivery models that prove to be successful.
In addition, beginning in 2011, the federal government will provide matching funds up to 90% for two years to states that allow Medicaid beneficiaries to receive care under the medical home model. PPACA also includes grants for the establishment of medical homes in community health systems.
In addition, the health reform law created the Primary Care Extension Program under the Agency for Healthcare Research and Quality. The program provides primary care training and assistance in implementing quality improvement or system redesign that incorporates the principles of the patient-centered medical home.
Medical Home and Meaningful Use
Under the HITECH Act, part of the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicare and Medicaid incentive payments.
Grundy said Stage 1 requirements for meaningful use "connect pretty well" to the patient-centered medical home.
For example, Stage 1 includes objectives for improving care coordination and engaging patients and their families in their health care -- both key elements of the medical home model.
Grundy also noted that all of the meaningful use requirements are built into the National Committee for Quality Insurance's standards for patient-centered medical homes. He said, "So if you become a medical home" and you meet the NCQA standards, "you automatically qualify for meaningful use."
Grundy said that as policymakers are developing requirements for Stage 2 and Stage 3 of the meaningful use program, they should look at making access more convenient for the patient, and increasing physician-patient communication and patient engagement.