If you aren't familiar (or know nothing about) what's been termed the medical home model or primary-care medical home, you've got company, certainly within the chiropractic profession. According to a recent ChiroPoll, only 16 percent of DCs said they are "very" or "somewhat" familiar with the medical home model, and more than half (55 percent) posed the question, "What is it?" With these figures in mind, let's take a closer look at the medical home model and see how it is reshaping the health care system, how all providers practice and the care their patients receive.
Medical Home Basics
A medical home is a model of primary care that endeavors to deliver patient-centered, comprehensive, coordinated care. Hallmark features of the medical home approach include integrated, accessible, cost-effective care that maximizes the patient's health experience and allows for continuous, systems-based improvements to quality and safety. It facilitates partnerships between individual patients, their health care providers, and even their family.
In short, it is a team approach to each patient's lifelong health that emphasizes communication, coordination and compassion. Health information technology, interdisciplinary relationships, practice organization, quality measures, preventive care and patient self-management are all essential components of the medical home.
The American Academy of Pediatrics, credited with introducing the medical home concept in the 1960s, describes it this way:
"A family-centered medical home is a trusting partnership between a child, a child's family and the pediatric primary care team who oversees the child's health and well-being within a community-based system that provides uninterrupted care with appropriate payments to support and sustain optimal health outcomes.
"Medical homes address preventative, acute, and chronic care from birth through transition to adulthood. A medical home facilitates an integrated health system with an interdisciplinary team of patients and families, primary care physicians, specialists and subspecialists, other health professionals, hospitals and healthcare facilities, public health and the community."
How does the medical home model impact chiropractic? Enter the Foundation for Chiropractic Progress, which just released "The Role of Chiropractic Care in the Patient-Centered Medical Home." The white paper, developed with guidance from, among others, a clinical advisory panel of chiropractors and medical doctors, provides an overview of the medical home model of care and explores the opportunities – both current and future – for doctors of chiropractic within such a model.
To find out more about the foundation white paper and the medical home model in general, we interviewed Guy D'Andrea, managing partner at Discern, LLC, the health care policy consulting firm that prepared the paper:
Give our readers some background on the medical home model including design, general structure, etc. Many doctors of chiropractic may not be aware of this model and how it can influence patient care in the near future (or how it may already be doing so). The patient-centered medical home (PCMH) is an advanced primary care model focused on team-based care that coordinates and manages patients' care across the health care continuum. In the PCMH:
- Care should be "team-based" (these teams can be "virtual", i.e., practicing in multiple locations).
- Each member of the team should "practice to the top of their license. The physician should not spend time on care that could be delivered as effectively and more efficiently by other members of the team.
- The PCMH will need to manage referral patterns to outside providers. This is typically discussed in terms of referral to specialist physicians, but can also apply to referrals to allied health professionals.
- PCMH payment models typically provide an incentive to lower patients' total costs of care (though the details of the payment models vary from market to market).
What are the potential advantages of this model of care from the perspective of the patient, the health care provider and the health care system in general? There are important conceptual differences between the PCMH and "traditional" primary care. "Traditional" primary care is reactive (wait for the patient to call), internally focused (What happens to the patient in our office?) and process / volume oriented; PCMH care is proactive (reach out to patients who need support), externally focused (What happens to the patient when they are not in our office?) and outcomes oriented.
Here's another way to think about the PCMH: There are 8,760 hours in a year. The 8,755 hours the patient is not in the doctor's office will have the greatest impact on outcomes and cost. Patients with chronic health conditions might especially benefit from the PCMH. Numerous studies have documented that chronically ill patients experience poor outcomes, often due to a lack of care coordination.
You worked with the Foundation for Chiropractic Progress on the white paper. Please summarize the main points of the paper and outline the role chiropractic could play in such a model and again, the benefits to patients, the profession/professional and the health care system. In the PCMH, primary care physicians will need to build care teams composed of both internal staff and external partners. The emergence of the medical home model creates an opportunity to define an important role for the Doctor of Chiropractic (DC) in the primary care setting.
The white paper argues that primary care providers (PCPs) and DCs should collaborate to deliver efficient and effective care for patients. This will be particularly important for patients with back pain, neck pain and headaches. Care for patients with these conditions is currently fragmented and would greatly benefit from increased care coordination. There is strong evidence that, for these health conditions in particular, chiropractic care produces outcomes that are as good or better, with lower costs and higher patient satisfaction compared to other health care delivery models. Given the high prevalence of neuromuscular and musculoskeletal conditions amenable to chiropractic care, effective PCMHs should aim to integrate chiropractic services into their care delivery process.
While the white paper generally focuses on the role of the [DC] as a member of the PCMH team, there is also an appendix that addresses the potential for the DC to lead the primary care process. The appendix documents federal and state policies that have been implemented which recognize the leadership role DCs can play in delivering high-quality, efficient health care.
What was the involvement of the chiropractic and the medical / health care community in the development of the white paper? In order to get an expert perspective on the role of chiropractic services in the PCMH model, we convened a Clinical Advisory Panel of MDs and DCs to offer their expert insights and ensure the development of appropriate, fair, and effective patient care and referral patterns between the PCMH and chiropractic care settings. Members of the panel are Mark T. Zeigler, DC, president, Northwestern Health Sciences University; Steven Kraus, DC, DIBCN, CCSP, FASA, FICC, CEO and founder, Future Health; Tom Evans, MD, president, Iowa Healthcare Collaborative; and John Hollingsworth, MD, MS, assistant professor, Department of Urology, University of Michigan Health Systems. The panel provided guidance for the development of the paper and supports the paper's conclusions on the following topics:
- Descriptions of clinical processes and indicators that could be used to refer patients from the medical home to a DC
- Description of processes for ongoing coordination of chiropractic care with medical home activities
- An analysis of the potential benefits of integrating chiropractic care into the medical home. Areas of focus can include quality outcomes and financial impact
- Clinical options that PCMH participating physicians have to address back and neck pain for their patients (including the use of chiropractic care)
In addition to the panelists, the Foundation for Chiropractic Progress also provided guidance on the development of the paper. FCP reviewers included Gerry Clum, DC, Michelle Maiers, DC, Chuck Sawyer, DC, and Dan Redwood, DC.
Are there potential hurdles/challenges to implementation of this type of model? If so, please describe, particularly as it may impact chiropractors and their patients. The main hurdles will be defining the relationship between primary care practices and DCs. How will information be shared (information technology will play an important role) and how will providers collaborate to deliver the best care for patients?
The financial relationship between primary care practices and DCs will also be a challenge. The primary care practices will be partially at risk (through shared savings programs) for the cost of care. Might DCs be willing to share in this risk?
To Learn More
While numerous organizations and Web sites provide information on the medical home model of care, the American Academy of Family Physicians offers an excellent overview in lay terms. It also features a checklist (not all areas will be relevant to DCs, of course) illustrating key service requirements of a medical home practice. For more information, click here. The Patient-Centered Primary Care Collaborative also provides a layperson-friendly video overview online.