What is Needed for the Patient Centered Medical Home to Reach its Full Potential?

When the Pickup Truck Meets the 18 Wheeler

Let’s take a quick look at what we know or at least what we may have read or heard.  A Rand Corporation study, presented in JAMA in 2014, compared a group of practices that had achieved patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) with a similar number of control practices that did not receive any special training. What the study reported, is that the medical home model was associated with only limited improvement within a range of quality measures and virtually no improvement in cost reduction.

No sooner were these findings published that proponents of the model cited dozens of private and public medical home-based examples where improvements in cost and quality had, in fact, been achieved and documented. Advocates also noted that the Rand study was based on a review of 2008 standards that have since been updated and was narrow in its focus, a limitation that is being addressed in new research that’s currently underway.

My personal experience as a primary care practitioner in a certified PCMH along with a great deal of observation around practices I’ve visited in various parts of the country over the past four years leads me to believe that the PCMH is a cornerstone of accountable care. It’s also a virtual requisite for meeting the Triple Aim of improving population health, the individual care experience and per capita costs.  At the same time, I think the section of the Rand report that suggests that “medical home interventions may need further refinement” may be right on  the money.

As we work with practices in how to effectively adopt a team care approach to primary care medicine, one of the essential building blocks for patient-centered care, we sometimes see administrators, practice managers, physicians and other staff who believe in the value of the medical home model and even imagine themselves to already be there or at least on the outskirts. In reality, they remain tied to the physician-centric approach of a traditional practice.

What they still haven’t accomplished is forming the kind of team where patients are able to develop a strong relationship with their doctor, clinical and non-clinical staff are empowered and trained to take on more aspects of care, particularly in the area of coordination and education, and physicians are enjoying a better work-life balance.

With these groups, I sometimes use the analogy of a six cylinder, gas fueled pickup truck being sufficient to meet the needs of their current practice but not adequate to power a medical home. Truly transforming the practice to a team care model and, ultimately, a patient-centered medical home requires more horsepower.  It’s time to get rid of the pickup and move toward a 12 cylinder diesel. The good news is that while investments in technology and staffing may likely be necessary, the proportional increase is not nearly as much as trading up from the pickup to the big rig.

Becoming a PCMH isn’t a matter of natural evolution. It takes the kind of concentrated effort along with the financial commitment I mentioned – particularly when it comes to additional staff – as well as the will to make the changes needed to go from doctor as point person to doctor as leader of a well-trained and high-functioning team.  It also takes the understanding that no matter how much you believe in the concept of team care and the medical home, no matter how solid your implementation plan, you still have to execute on it. And for that you’re likely to find that you just may need a bigger engine.