Defining a Medical Home

We recently attended the South Florida Hospital and Healthcare Association’s 2009 Healthcare Summit and in a breakout session, the question was asked of the five panelists, “How do you define the term “medical home?” Five different definitions from the five panelists! Although some components of the panelists’ definitions were similar, what was clear that there exist multiple interpretations of the “medical home” concept.

President Obama, HHS Secretary Kathleen Sebelius, and Nancy-Ann DeParle, Director of the White House Office of Health Reform have suggested that the medical home model should be an integral part of healthcare reform. But how do we define a medical home? The concept of medical homes is not new. The words ‘medical homes’ were first used in 1967 to describe a source or venue of healthcare delivery for children. In a 1992 policy statement, the American Academy of Pediatrics (AAP) published a proposed definition describing the medical home as “medical care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally affective.”

In 2002, the AAP issued a new policy statement that provided an expanded and more comprehensive interpretation of the concept as well as and an operational definition of the medical home. The updated definition included characteristics to assure that (1) family-centered included all members of the family, (2) unbiased, culturally sensitive information was provided on an ongoing basis that includes not only health but also community assets that could be is accessed by the family, and (3) continuous included that the same primary pediatric health care professionals was available from infancy through adolescence and young adulthood.

However, the medical home concept has expanded beyond pediatrics. In 2006, the Patient-Care Primary Care Collaborative (PCPCC) was created as a coalition of major employers, consumer groups, organizations representing primary care physicians, and other stakeholders whose goals are to facilitate improvements in patient-physician relations, and create a more effective and efficient model of health care delivery. To achieve these goals, the PCPCC has become one of the major advocates of the Patient Centered Medical Home (PCMH) model in the nation. See: http://www.pcpcc.net/.

The PCPCC defines the PCMH as “an approach to providing comprehensive primary care to adults, youth and children.” The PCPCC advocates for the following key features, which are based upon the “Joint Principles of the Patient-Centered Medical Home,” developed in 2007 by four primary care specialty societies—representing more than 300,000 internists, family physicians, pediatricians, and osteopaths:

• Each patient has access to a primary care physician within the practice who is responsible for providing comprehensive, preventive, and longitudinal care of the whole person, working in a collaborative way with nurses, physician specialists and other health care professions involved in the patient’s care.
• Enhanced Access and Open Scheduling
• Adopting and Implementing Evidence Based Guidelines
• Systematic, HIT based tracking of tests, results, screens, preventative therapy
• Referral tracking, and follow-up
• Alternate forms of patient-physician interaction (email, phone)
• Accountable for reporting on evidence-based measures of quality and patient satisfaction.

In brief, the PCPCC views a PCMH as a primary care practice that it is able to deliver comprehensive, patient-centered care of the whole person, supported by health information systems and with accountability for results.

To date, the National Committee on Quality Assurance (NCQA), supported by the Commonwealth Fund, has certified approximately 800 physicians as patient-centered medical homes (PCMH). Using 9 standards that emphasize the use of systematic, patient-centered, coordinated care management processes within three levels, the NCQA defines a PCMH as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.” (see sidebar).

In 2008, the Centers for Medicare and Medicaid (CMS) released its description of a medical home as part of its mandated Medical Home Demonstrated Project under the Tax Relief and Health Care Act of 2006. CMS describes a medical home as physicians’ practices that can demonstrate they have the capabilities to provide services within six domains: continuity of care, clinical information systems, delivery system design, decision support, patient/family engagement, and care coordination. Adapting NCQA’s Physician Practice Connections-Patient Centered Medical Home (PCC-PCMH), the six domains consist of 28 specific core capabilities, with Tier I or “typical” medical home having 17 basic medical home capabilities, and Tier II or “enhanced” medical home having the Tier I requirements plus 4 additional capabilities (electronic medical record, coordination of care including follow-up of inpatient and outpatient care, measures of performance, and reporting to physicians. (For more information, see the Medical Home Demonstration webpage on CMS’ website).

These various definitions of “medical home” make it difficult to determine precisely what President Obama, HHS Secretary Sebelius, and Director DeParle and others envision as medical homes and the part they will play in the nation’s healthcare reform.