The utopian medical home

September 1, 2010

Utopian medical practice would run seamlessly even if you were out of the office, wouldn't it?

Utopian medical practice would run seamlessly even if you were out of the office, wouldn't it? In some places, Utopia is a reality because the technology exists. How does technology translate into improving patient care? And how will it pay for itself, or more accurately, provide the mechanism by which it will pay for itself? What's your next step?

The framework for answering these questions is likely familiar: the medical home. The American Academy of Pediatrics (AAP) and the federal Maternal and Child Health Bureau define a medical home as a medical practice that is "accessible and family-centered and provides high-quality care that is comprehensive, coordinated, compassionate and continuous over time." The patient-centered medical home (PCMH) embraces 7 major principles as outlined in a 2002 joint statement by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association. They are: a personal physician, a physician-directed medical practice, a whole-person orientation, coordinated/integrated care, an emphasis on quality and safety, enhanced access to care, and payment that reflects the added value of the medical home. Most primary care physicians informally strive to provide this type of care. Technology and vision can make it easier, even automatic, for your practice to be a medical home.

Payers are watching for this, too. Many measures of a successful medical home are the ones that insurance companies, Medicare, and Medicaid are examining for pay for performance. They are integral to the goals of the Patient Protection and Affordable Care Act (PPACA, or the healthcare reform bill). Some payers will offer additional payments to providers just to be a medical home. Formal medical home certification processes exist through the National Committee for Quality Assurance. Information is easily available from Web sites such as http://www.medicalhomeimprovement.org/ and http://www.medicalhomeinfo.org/, among others, to help any medical practice become a medical home to its patients.

Meet our imaginary patient, Sally Jenkins. Sally is a 7-year-old girl with a history of allergic rhinitis and asthma. Today, she came home from school wheezing. Her mother, Mrs Jenkins, initiated home treatment according to the asthma action plan prepared by Dr K, Sally's pediatrician. By 6:30 PM, her breathing had not improved, so Mrs Jenkins called Alpha Peds Clinic, where Dr K's partner, Dr L, was seeing patients. He instructed Mrs Jenkins to bring her daughter in.

Every patient should have a doctor the family calls first with most issues. Realistically, a physician can't be expected to be available for every patient at any time, but the physician is the leader of the team that can be available, in some form, at any time. That form may be in-office, in-hospital, or via telephone, Internet, or text and may range from hands-on service to simply triage.

Physician-directed medical practice

"You're not my doctor," says Sally, as Dr L walks into the exam room. Sally has a strong connection to Dr K and knows she's her doctor. However, Sally and Mrs Jenkins recognize Dr L and can identify Alpha Peds Clinic as her medical home. They are impressed with all of the information about Sally that Dr L can discuss, most of which he simply reads off of his computer screen.

Dr K is the team leader for Sally's care but doesn't need to do all the work himself. The clinic has a care coordinator who is notified of Sally's needs after her visit. The care coordinator may make referrals and follow-up on important tasks, including communication with Mrs Jenkins. After Sally's visit, Dr K will be made aware of the visit and its results. All of the documentation will be available on the computer almost immediately after the visit. This is important for follow-up, but should Sally need to be seen in an emergency room or by another provider, information can also be made available at that time to any provider involved in her care.

Whole-person orientation

Sally's medical record brings up an alert that Sally has not had her flu shot. This will be offered to Sally before she leaves the clinic. If Dr L decided that Sally should not get this shot today, the system will create a reminder for her to return. The reminder can be sent directly to Mrs Jenkins via a secure e-mail system, text messaging, phone, mail, or whatever is the preferred contact method. Again, the care coordinator follows up and helps the family arrange the appointment.

The system also notes that Sally may be overdue for her dental check-up. The care coordinator can help arrange this, but Mrs Jenkins has already made the appointment for next week. This information is noted in the record. In the event of any dental issues, the dentist on file is asked to communicate with the primary physician's office.