Medical Homes: Challenges in Translating Theory Into Practice

Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA.
Medical care (Impact Factor: 3.23). 08/2009; 47(7):714-22. DOI: 10.1097/MLR.0b013e3181a469b0
Source: PubMed


The concept of the medical home has existed since the 1960s, but has recently become a focus for discussion and innovation in the health care system. The most prominent definitions of the medical home are those presented by the Patient-Centered Primary Care Collaborative, the National Committee for Quality Assurance, and the Commonwealth Fund. These definitions share: adoption of health information technology and decision support systems, modification of clinical practice patterns, and ensuring continuity of care. Each of these components is a complex undertaking, and there is scant evidence to guide assessment of diverse strategies for achieving their integration into a medical home. Without a shared vocabulary and common definitions, policy-makers seeking to encourage the development of medical homes, providers seeking to improve patient care, and payers seeking to develop appropriate systems of reimbursement will face challenges in evaluating and disseminating the medical home model.

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    • "Medical homes started in the US in the 1960s primarily in treating chronically ill children, as pediatricians sought to improve coordination with specialists and maintain a common medical record (Sia et al., 2004). Managed care provided further impetus for medical homes (Institute of Medicine, 2001), as did endorsements of such coordination by national physician associations in 2004 (Future Committee, 2004) and operationalization of medical homes practices in 2005 (Carrier et al., 2009). "
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    ABSTRACT: Throughout the United States, public health leaders are experimenting with how best to integrate services for individuals with complex needs. To that end, North Carolina implemented a policy incorporating both local public health departments and other providers into medical homes for low income pregnant women and young children at risk of developmental delays. To understand how this transition occurred within local communities, a pre-post comparative case study was conducted. A total of 42 people in four local health departments across the state were interviewed immediately before the 2011 policy change and six months later: 32 professionals (24 twice) and 10 pregnant women receiving case management at the time of the policy implementation. We used constant comparative analysis of interview and supplemental data to identify three key consequences of the policy implementation. One, having medical homes increased the centrality of other providers relative to local health departments. Two, a shift from focusing on personal relationships toward medical efficiency diverged in some respects from both case managers' and mothers' goals. Three, health department staff re-interpreted state policies to fit their public health values. Using a political economy perspective, these changes are interpreted as reflecting shifts in public health's broader ideological environment. To a large extent, the state successfully induced more connection between health department-based case managers and external providers. However, limited provider engagement may constrain the implementation of the envisioned medical homes. The increased focus on medical risk may also undermine health departments' role in supporting health over time by attenuating staff relationships with mothers. This study helps clarify how state public health policy innovations unfold at local levels, and why front line practice may in some respects diverge from policy intent.
    Social Science [?] Medicine 10/2015; 145:98-106. DOI:10.1016/j.socscimed.2015.10.003 · 2.89 Impact Factor
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    • "As with any new healthcare structure, current PCMH practices are still developing methods to improve the quality of care provided to their patients, such as care coordination, team-based care, and the use of EMR to promote care coordination. There continues to be a struggle for transitioning PCMHs in determining how to implement the guidelines that the NCQA provides, which is a concern because NCQA is the most widely recognized organization in the United States for certifying practices as PCMHs [27]. NCQA recognition of PCMH does not require primary care practices to excel at every standard, but rather it requires a system of documentation about the quality of care being provided, and a plan for continuous improvement that follows each of the principles. "
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    ABSTRACT: The Patient-Centered Medical Home (PCMH) is a primary care model that provides coordinated and comprehensive care to patients to improve health outcomes. This paper addresses practical issues that arise when transitioning a traditional primary care practice into a PCMH recognized by the National Committee for Quality Assurance (NCQA). Individual organizations' experiences with this transition were gathered at a PCMH workshop in Alexandria, Virginia in June 2010. An analysis of their experiences has been used along with a literature review to reveal common challenges that must be addressed in ways that are responsive to the practice and patients' needs. These are: NCQA guidance, promoting provider buy-in, leveraging electronic medical records, changing office culture, and realigning workspace in the practice to accommodate services needed to carry out the intent of PCMH. The NCQA provides a set of standards for implementing the PCMH model, but these standards lack many specifics that will be relied on in location situations. While many researchers and providers have made critiques, we see this vagueness as allowing for greater flexibility in how a practice implements PCMH.
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    • "If these specific PCMH " care coordination " interventions work in the intended manner, then expected outcomes would include improved quality of care, lower utilization of high-cost services, enhanced patient experiences with their care, and lower system costs resulting from the delivery of more appropriate care for the patient (see Rosenthal, 2008). Most agree, given the joint PCMH principles put forth and agreed upon nationally (PCPCC, 2012a; Figure 1), that the PCMH is meant as a comprehensive model of primary care delivery (see Carrier et al., 2009; see also Friedberg et al., 2009). As a result, unless everyday primary care settings implement multiple interventions that include a combination of the general principles listed in Figure 1 the care model defining that practice setting falls short of true medical home care. "
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    ABSTRACT: The patient-centered medical home is an important innovation in health care delivery. There is a need to assess the scope and substance of published research on medical homes. This article reviews published evaluations of medical home care for the period 2007 to 2010. Chief findings from these evaluations as a whole include associations between the provision of medical home care and improved quality, in addition to decreased utilization associated with medical home care in high-cost areas such as emergency department use. However, fewer associations were found across evaluations between medical home care and enhanced patient or family experiences. The early medical home research appears to reflect both the wide variation in how medical homes are being designed and implemented in practice and in how researchers are choosing to evaluate patient-centered medical home design and implementation. While some aspects of medical home care show promise, continued evolution of medical home evaluative research is needed.
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