The patient-centered medical home: will it stand the test of health reform?
ABSTRACT The fundamental challenge for health care reform in the United States is to expand access to all US residents, while rapidly reengineering the delivery system to provide consistently high-quality care at lower overall cost. Current reform discussions recognize that success will require a shift in emphasis from fragmentation to coordination and from highly specialized care to primary care and prevention.One prominent model of delivery system reform is the patient-centered medical home (PCMH). Crafted by the primary care professional organizations in 2007, the model has been endorsed by a broad coalition of health care stakeholders, including all of the major national health plans, most of the Fortune 500 companies, consumer organizations and labor unions, the American Medical Association, and a total of 17 specialty societies.1 Currently, 22 multistakeholder demonstration pilot projects are under way in 14 states, and the Centers for Medicare & Medicaid Services will conduct Medicare demonstration pilot projects in 400 practices in 8 regional sites in 2009.2- 3 Twenty bills promoting the PCMH concept have been introduced in 10 states.4
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ABSTRACT: Background The emerging field, Lifestyle Medicine (LM), is the evidence-based practice of assisting individuals and families to adopt and sustain behaviors that can improve health. While competencies for LM educatio n have been defined and undergraduate curricula have been published, there are no published reports that address graduate level fellowship in LM. This paper describes the process of planning a LM fellowship curriculum at a major, academic teaching institution.Methods In September 2012 Harvard Medical School Department of Physical Medicine and Rehabilitation approved a ¿Research Fellowship in Lifestyle Medicine¿. A Likert scale questionnaire was created to measure LM stakeholders¿ perceived relative importance of six domains and eight educational experiences to possibly include in the syllabus of this one-year LM fellowship (1¿=¿not important; 5¿=¿very important). The survey was sent to forty relevant professionals worldwide. Equity in variance within each educational topic (LM domains; educational experiences) was calculated using the analysis of variance and comparison between them using Wilcoxon signed-rank test.ResultsThirty-five of the forty stakeholders (87.5%) completed the survey. All domains except smoking cessation were graded at 4 or 5 by at least 85% of the respondents. After excluding smoking cessation, the difference among the remaining five domains is non-significant (p¿=¿0.12). Thus, nutrition, physical activity, behavioral change techniques, stress resiliency, and personal health behaviors were judged equally as important components of a LM fellowship curriculum (average M¿=¿4.69, SD¿=¿0.15).All educational experiences, with the exception of completing certification programs, research experience and fund raising, were graded at 4 or 5 by at least 82% of the responders. After excluding these three, the difference among the remaining educational experiences did not reach statistical significance (p¿=¿0.07). Thus, clinical practice, teaching physicians and medical students, teaching other health care providers, developing lifestyle interventions and developing health promotion programs were supported and perceived as comparably important in a LM fellowship program (average M¿=¿4.23, SD¿=¿0.11).Conclusions Lifestyle fellowship curricula components were defined based on LM stakeholders¿ input. These five domains and five educational experiences represent the range of competencies previously noted as important in the practice of LM. As the foundation of an inaugural physician fellowship, they inform the educational objectives and future evaluation of this fellowship.BMC Medical Education 12/2014; 14(1):1045. DOI:10.1186/PREACCEPT-1126245053135251 · 1.41 Impact Factor
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ABSTRACT: Care management has become a widespread strategy for improving chronic illness care. However, primary care provider (PCP) participation in programs has been poor. Because the success of care management relies on provider engagement, understanding provider perspectives is necessary. Our goal was to identify care management functions most valuable to PCPs in hypertension treatment. Six focus groups were conducted to discuss current challenges in hypertension care and identify specific functions of care management that would improve care. The study included 39 PCPs (participation rate: 83 %) representing six clinics, two of which care for large African American populations and four that are in underserved locations, in the greater Baltimore metropolitan area. This was a qualitative analysis of focus groups, using grounded theory and iterative coding. Providers desired achieving blood pressure control more rapidly. Collaborating with care managers who obtain ongoing patient data would allow treatment plans to be tailored to the changing life conditions of patients. The P.A.R.T.N.E.R. framework summarizes the care management functions that providers reported were necessary for effective collaboration: Partner with patients, providers, and the community; Arrange follow-up care; Resolve barriers to adherence; Track treatment response and progress; Navigate the health care system with patients; Educate patients & Engage patients in self-management; Relay information between patients and/or provider(s). The P.A.R.T.N.E.R. framework is the first to offer a checklist of care management functions that may promote successful collaboration with PCPs. Future research should examine the validity of this framework in various settings and for diverse patient populations affected by chronic diseases.Journal of General Internal Medicine 12/2014; 30(4). DOI:10.1007/s11606-014-3130-4 · 3.42 Impact Factor
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ABSTRACT: Primary care practice transformations require tools for policymakers and practice managers to understand the financial implications of workforce and reimbursement changes. To create a simulation model to understand how practice utilization, revenues, and expenses may change in the context of workforce and financing changes. We created a simulation model estimating clinic-level utilization, revenues, and expenses using user-specified or public input data detailing practice staffing levels, salaries and overhead expenditures, patient characteristics, clinic workload, and reimbursements. We assessed whether the model could accurately estimate clinic utilization, revenues, and expenses across the nation using labor compensation, medical expenditure, and reimbursements databases, as well as cost and revenue data from independent practices of varying size. We demonstrated the model's utility in a simulation of how utilization, revenue, and expenses would change after hiring a nurse practitioner (NP) compared with hiring a part-time physician. Modeled practice utilization and revenue closely matched independent national utilization and reimbursement data, disaggregated by patient age, sex, race/ethnicity, insurance status, and ICD diagnostic group; the model was able to estimate independent revenue and cost estimates, with highest accuracy among larger practices. A demonstration analysis revealed that hiring an NP to work independently with a subset of patients diagnosed with diabetes or hypertension could increase net revenues, if NP visits involve limited MD consultation or if NP reimbursement rates increase. A model of utilization, revenue, and expenses in primary care practices may help policymakers and managers understand the implications of workforce and financing changes.Medical Care 12/2014; 53(2). DOI:10.1097/MLR.0000000000000278 · 2.94 Impact Factor