In 2009, five of the primary-care health centers in Wisconsin-based Dean Health System began to transform into an increasingly popular—but, to many, still somewhat fuzzy—feature of the new healthcare landscape: the “patient-centered medical home.”
The goals are noble: Orient and guide the patient through the healthcare system. Don’t repeat tests already performed. Keep costs down. Prevent illnesses that are, in fact, preventable. And reward doctors for doing so rather than encouraging visit after visit and test after test.
The hospitalists in the Dean system were brought late into the patient-centered medical home, or PCMH, project, but are now more involved:
- They participate in discussions about impending hospitalizations for patients to determine whether hospitalization is really needed;
- They make every effort to assign the same doctor to a patient each time the patient is hospitalized; and
- They also are part of admissions and discharges that are smoother due to efforts to keep information flowing and keep patients in formed.
There have been hiccups, though. Dean hasn’t tracked readmission rates, so it isn’t known whether they’ve improved. And satisfaction ratings from patients haven’t improved—in part, says Kevin Eichhorn, MD, chief of the hospitalist division at Dean, because patients don’t fully appreciate the changes that have been made, although there is an effort to tell them.
—Ken Simone, DO, SFHM, principal, Hospitalist and Practice Solutions
“But we’ve also only been doing this routinely for about a year,” Dr. Eichhorn says. “My hope is that, as we get better at it, we will see some improvement in terms of patient satisfaction with their hospitalization and improvement in other quality metrics as well.”
If hospitalists already working in a PCMH model are struggling with the changes, imagine the question marks for hospitalists who aren’t familiar with the concept yet (see “The Patient-Centered Medical Home: A Primer,” below). Joseph Ming Wah Li, MD, SFHM, immediate past president of SHM, says most hospitalists are not.
“I think it’s fair to say that most hospitalists lack awareness and insight into what the patient-centered medical home will mean for patients and for hospitalists,” he says.
But it’s a concept HM as a whole should bone up on quickly. As attention to reducing healthcare costs intensifies and the PCMH model becomes more commonplace, hospitalists’ roles within such practices will increase.
Some say hospitalists will be hired by primary-care practices that previously did not employ hospitalists. They might provide extra help during transitions by following patients as they are discharged to skilled rehab units or nursing homes. They also might provide preoperative histories for elective surgeries.
“I believe the hospitalist will be right at the center of the model, along with the PCPs [primary-care physicians],” says Ken Simone, DO, SFHM, a national hospitalist practice management consultant and principal at Maine-based Hospitalist and Practice Solutions. “In my opinion, the PCMH model will expand the hospitalist’s role outside the four walls of the hospital.”
Time to Prepare
Dr. Simone and others say that now is the time for hospitalists to begin exploring the PCMH model and its implications in their locales. HM groups should:
Familiarize themselves with the PCMH concept.
Although the model continues to evolve, the main components can be found in a 2007 joint statement by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.1 They include the principles of a personal physician with whom the patient has an ongoing relationship; coordinated care across all elements of the healthcare system; better quality and safety; enhanced access to doctors and their teams; and a payment system that factors in the role of physicians and nonphysicians alike, as well as the role of technology and rewards for good outcomes.
“In a patient-centered medical home, there is a strong emphasis on coordination of care and communication between all members of a patient’s healthcare team,” says Jeffrey Cain, MD, president-elect of the American Academy of Family Physicians (AAFP). “Patients receive the highest-quality, patient-centered care when the primary-care physician takes the lead in coordinating care. This means keeping patients, specialists, hospitalists, and other health providers informed of all test results, treatment plans, expectations, progress, and outcomes.”
Find out about the PCMH activity in their own communities.
Dr. Cain said that the degree of PCMH adoption depends on where you work.
“It is spotty throughout the United States,” he notes. “There are areas of tremendous growth and areas that are waiting to have that happen.”
Dr. Simone, a Team Hospitalist member, says the degree to which hospitalists are familiar with PCMH depends on the level of adoption in the area.
“I have found greater hospitalist awareness in communities that have integrated healthcare delivery systems,” he says. “This makes sense, because these are the communities that are aggressively pursing the patient-centered home.”
Forge relationships with primary-care providers.
Dr. Simone encourages hospitalist groups to make marketing visits to local PCP offices. During these visits, hospitalists should discuss the services they provide, their staffing model, admission and communication protocols—and, “most importantly, ask what the hospitalist practice can do to meet the needs of both the patient and the referring providers.”
Dr. Li says it’s always been important to have open lines of communication with your PCPs—but now more than ever.
“If you don’t have this already, you’re already behind in the ballgame,” he says. “But it’s never too late. It’s critically important to have those communication systems in place so that patients get the best care possible.”
Talk to hospital administrators about clinical and financial links with PCMH practices.
The time to do this, Dr. Simone says, is when a local PCMH is being created, or at contract renewal time, if a PCMH is already exists.
“Hospitalists will obviously need to have a voice within the organization and some autonomy for them to commit to such an integrated relationship,” Dr. Simone says.
Prepare for the demands of sicker patients.
If better primary care means fewer hospitalizations, the patients who are admitted will be sicker, posing more challenges to hospitalists.
“Make sure each individual provider has the skill set and schedule that allows them to take care of these patients,” Dr. Li says.
Embrace the possibilities this model offers.
In the PCMH model, the coordination between the hospitalist and the PCP can only help a hospitalist at the time of discharge.
“It will be easier to get their patients into a primary-care office,” says Dr. Cain of AAFP.
David Meyers, MD, director of the Center for Primary Care, Prevention and Clinical Partnerships at the federal Agency for Healthcare Research and Quality (AHRQ), which provides tools and information that support primary care’s redesign and the PCMH, says the model essentially adds a member to the hospitalist’s team.
“If done well, it gives the hospitalist a partner in the community with whom to establish joint accountability,” Dr. Meyers explains. “In addition to establishing accountability, the PCMH helps ensure information flows both into and out of the hospital.”
A Growth Spurt
As of March 1, the nonprofit National Committee on Quality Assurance had recognized 3,979 practices across the country as “patient-centered medical homes.” And that doesn’t include practices that function according to PCMH principles but are not officially recognized.
The Mayo Clinic recently began a three-year pilot PCMH project in Wisconsin, in conjunction with Group Health Cooperative of Eau Claire.
Crucially, insurance companies are coming on board. In January, Indianapolis-based benefits company WellPoint announced a new payment system designed to promote better primary care, with increases to regular fees, payments for “non-visit” services, and shared savings payments based on quality outcomes and reduced medical costs.
Blue Cross and Blue Shield has reported success with PCMH models.
Meanwhile, the Centers for Medicare & Medicaid Services (CMS) is testing a PCMH model to see whether it generates higher quality of care and cost savings. So is the Department of Veterans Affairs.
—David Meyers, MD, director, Center for Primary Care, Prevention and Clinical Partnerships, Agency for Healthcare Research and Quality, Washington, D.C.
Primary-care doctors, hospitalists and government officials say the concept is likely here to stay. “We’re in a period of change,” Dr. Meyers says. “I don’t know where we’re going to be in five years from now, but forces are aligning such that this may really work.”
And hospitalists are vital to the success of any PCMH.
“The patient-centered medical home,” he says, “to be effective on what it can do, has to be integrated into a patient-centered medical neighborhood—the partnership between primary care or ambulatory care and inpatient care, and specifically the hospitalists and those folks working in nursing homes and skilled nursing facilities.”
Gordon Chen, MD, a cardiologist and senior vice president of medical affairs at Chen Medical in Miami, where a number of PCMH concepts have been in place for 10 years, says that he works both with hospitalists employed by Chen Medical and some not employed by Chen Medical. And he notices the difference.
“It can be a little bit more difficult to reach and to coordinate and collaborate with other physicians, but we can do it,” he says.
A tighter connection allows information to flow better between the PCPs and the hospitalists, he points out.
“One of the most frustrating things as a physician is to find out that your patient had a prolonged hospitalization and they come to see you in the clinic and you don’t have any information,” Dr. Chen says. “You look at this new medication list and you’re trying to put the pieces together. When a doctor doesn’t have all the information, and is guessing … it leads to poor decisions being made.”
Back at Dean Health System in Wisconsin, Dr. Eichhorn is confident that the concepts behind the patient-centered medical home can only be good for patients. Still, the project there—as at many other places—is a work in progress.
“Emphasizing wellness and preventative health certainly conveys significant benefits,” he says. “The challenge is defining what is a patient-centered medical home. It sounds like every group is struggling what that means and how to define it and then how to track your outcomes. And then does the patient have a sense of that? Are they appreciating something different in what’s happening to their healthcare?”
Thomas R. Collins is a freelance writer in South Florida.