Volume 61, Number 3 - Summer 2010

 

By Bo Greaves, MD

Americans have focused more on their health care system in the past year than in generations. The immediate result has been passage of needed insurance reform that will bring coverage to about 38 million uninsured citizens and eliminate some egregious injustices, such as refusing coverage for pre-existing conditions.

A byproduct of the debate over health reform has been a wider and deeper appreciation of the deficiencies of our current system. Many people are now aware that the United States spends more on health care than any other nation in the world, yet ranks near the bottom of developed countries in most measures of health outcomes. Adding 38 million more people to the current system without addressing these deficiencies could accelerate our problems to the point of system collapse. 

This possibility has increased attention on the role of primary care as the foundation of an improved health system. In particular, two propositions are emerging with more clarity than ever:

• The key to improving outcomes and reducing costs is for every American to have a reliable relationship with a full-service source of primary care.
• To maximize the benefit to the health care system and the country, we need to transform how we deliver primary care.

Major efforts to transform primary care have already started. Family physicians, pediatricians and internists are modernizing primary care practice with fundamental changes in access and communication, quality improvement, care coordination, comprehensive care, team approaches, and the use of health information technology. Their goal is to change their practices into “patient-centered medical homes.” 

What is a patient-centered medical home? A PCMH is a model of health care delivery that is based on patients having an ongoing personal relationship with a primary care physician or, in certain settings, a primary care nurse practitioner. This close patient/clinician relationship fosters continuous and comprehensive health care. The personal clinician leads a team of health care professionals who collectively take responsibility for the ongoing care of the patient.

A whole person orientation is a key component of the PCMH. The personal clinician provides for all the patient’s health care needs or takes responsibility for managing care with other qualified professionals, including acute care, chronic care, preventive services, and end-of-life care.

The personal clinician coordinates care across all elements of the patient’s community, including consulting specialists, hospitals, home health agencies, nursing homes, and other components of the health care system. Care is facilitated through registries, information technology, health information exchanges and other means to ensure patients get the indicated care when and where they need and want it.

Quality and safety are hallmarks of the PCMH. Practices that adopt the PCMH model become advocates for their patients to attain the best health outcomes. The care planning process is driven by a compassionate and robust partnership between the patient, the patient’s primary clinician, other health care providers, and family members. The patient actively participates in decision making and provides feedback to ensure that expectations are being met.

In a PCMH, evidence-based medicine and clinical decision-support tools guide decision making. Physicians and nurse practitioners in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measures. Information technology supports optimal patient care, performance measurement, patient education, and enhanced communication.

The enhanced access to health care in a PCMH means the practice provides patients with options such as open scheduling, expanded hours, and various arrangements for communication between patients, the clinician, the practice team, and office staff.

The new health reform legislation contains dozens of references to the PCMH. Both Medicare and health insurance companies are implementing demonstration projects aimed at showing that this approach can improve health care outcomes at a significantly lower overall cost. 

The National Committee on Quality Assurance has developed a system to assess and certify practices as a PCMH. One thing is clear: usual care in a primary care office today is not the same as the standards set by this new model of care. Before our practices can become certified as a PCMH, fundamental changes will need to occur in our offices, and in how we provide care to our patients. 

Financial incentives for becoming a PCMH are in the works as well. Medicare, for example, has adopted a “care management fee” above and distinct from its fee-for-service payments. Initially, the fee will be offered in Medicare’s demonstration projects. In order to receive this substantial extra revenue, a practice will need to prove (by NCQA or some other process) that it is functioning as a PCMH. Major insurers are also expected to adopt some payment methods to provide more revenue to primary care practices that are PCMHs, and less to those that are not. 

In March, nine family medicine practices from around Sonoma County launched a nine-month PCMH Learning Collaborative sponsored by Sonoma County Health Action with grant support from The California Endowment. In the health care setting, a collaborative is a group of different practices or hospitals who join together for a defined time period to make improvements through focused efforts. Collaboratives have been used for several decades to foster rapid improvements in hospitals and offices. The participants carry out intensive efforts, apply accepted methods of rapid improvement, and share their results with each other. 

Each practice in the Learning Collaborative is committed to making the transformations required to become a PCMH and hopes to make substantial strides in implementing needed changes by the end of 2010. Participating practices include health centers in Alexander Valley, Petaluma, Santa Rosa (2 locations), Sonoma Valley and West County, along with Kaiser Permanente (2 modules) and Sutter Pacific Medical Foundation.

Each practice has completed an initial assessment of its current performance in the nine elements of PCMH certification. Most practices are focusing their efforts on those elements where they scored the lowest. In addition, each practice has formulated a statement of specific goals they plan to accomplish by December. 

A special feature of the Learning Collaborative has been the inclusion of patients in the learning sessions and improvement teams at each practice. Some practices have identified an individual patient who serves as the patient voice in their efforts, while others are developing patient advisory groups. The inclusion of patients in transforming how we give care reflects the move to truly patient-centered care.

At the March kick-off session for the Learning Collaborative, Dr. John Saultz, chair of family medicine at Oregon Health Sciences University, linked the efforts to transform primary care both to national health reform and to local initiatives to improve community health. His speech was followed by interactive presentations on how to approach quality improvement in a practice setting and on successful team-building. During the remainder of the session, the teams from each practice developed their PCMH quality improvement projects with goals and action plans. 

The second session, held in May, focused on change management. Given that change is always stressful and can lead to a variety of reactions from staff, this session helped the teams anticipate and understand the possible reactions to change. Each team then had ample time for focused work on their PCMH transformation projects. 

Future sessions, including both teleconferences and in-person meetings, are planned over the remainder of 2010. Topics will meet the needs identified by the participating teams. The goal is to give each practice the tools they need to become a PCMH. 

While these sessions are important, the most valuable work occurs as each team plans and implements the necessary changes. Learning Collaborative staff offers technical assistance between sessions to help solve problems as they arise. In December, when the Learning Collaborative concludes, each team will reassess their performance on the nine elements of PCMH certification to see how far they have progressed toward the goal of becoming a certifiable PCMH.

Depending on funding and on the outcome of the Learning Collaborative, other collaboratives aimed at helping primary care practices in Sonoma County transform themselves into PCMHs may be planned for next year. This planning is in keeping with Health Action’s stated goal that every Sonoma County resident will have a Patient Centered Medical Home by the year 2020.

For more information about the PCMH Learning Collaborative, or to participate in future collaboratives, contact Pamela Moore at pmoore@rchc.net or Dr. Bo Greaves at greaveL@sutterhealth.org.