Communication among patients, families, the pcmh, and other members of the care team is called:

Patient-Centered Medical Home

The medical home model, also referred to as the “patient-centered medical home” (PCMH) refers to the model of carein which a primary care physician provides comprehensive care to improve health outcomes for a population of patients.48 The critical element of the PCMH is the coordination of care to reduce emergency room visits and hospitalizations. In managing the patient population, a number of strategies are implemented to reduce costs and improve outcomes. These models often utilize additional providers, including advance practice nurses, respiratory therapists, physical therapists, and patient advocates to manage chronic diseases such as asthma, chronic obstructive pulmonary disease, heart failure, and diabetes mellitus. Payment for the PCMH includes FFS payments for episodes of care as well as payment to coordinate care. This model has been successful in improving care, particularly for patients with selected chronic diseases, although the financial success has not been consistently achieved.49-51 In some cases, the PCMH actually resulted in increased hospital admissions.52 Despite the variable success of the PCMH, there are some lessons that can be applied to perioperative care. First, preoperative assessment must be comprehensive enough to identify underlying clinical problems and effectively manage them, both preoperatively and postoperatively (also seeChapter 31). For the anesthesiologist managing the perioperative period, chronic conditions must be addressed; the management of these cannot be deferred to other providers. The implications of the perioperative needs must be taken into account when managing chronic diseases during the course of surgical care. Second, the underlying medical conditions must be considered as part of the proposed procedure and its implications for postoperative management. This broader perspective requires coordination with the surgeon and for some patients, the hospitalist, other specialists, and the primary care provider. For example, a patient with peripheral neuropathy associated with diabetes mellitus may be unable to participate in traditional approaches to rehabilitation; care must be tailored to the specific needs of each patient in consultation with others who can modify care as needed to optimize likelihood of achieving the desired outcome. Third, while participation by anesthesiologists is essential, many aspects of perioperative care can be managed by other providers, including other physicians and advance practice nurses. The keys to successful perioperative management, however, require that there be a single physician responsible for coordinating care among the team of providers, ensuring consistent and ongoing communication about patient care needs, and the availability of data that can be used to analyze clinical and business practices, costs of care, and outcome measures. The responsible provider during the perioperative period may be the anesthesiologist, surgeon, or hospitalist. As the patient recovers, the responsible provider may transition to the primary care provider, as long as there is good communication and appropriate “hand-off.”

Patient-Centered Medical Home Models

One approach to improve patient care and lowering health care costs is the Patient-Centered Medical Home – an organization model for the delivery of the core components of primary health care. In 1967, the American Academy of Pediatrics first introduced the idea of a “medical home,” in order to provide a central location for children's medical records. In 2002, the AAP expanded this concept by identifying “Joint Principles.” The Patient-Centered Medical Home model is a team-based approach to care emphasizing patient support and empowerment, coordination and continuity of care, ease of communication between the patient and his or her and health care team, timely access to care, and “whole person” care. Whole person care assumes that the physician and his or her team are responsible for providing or arranging patients' care across the lifespan and considering patients' cultural traditions, personal preferences and values, family situations, social circumstances, and lifestyles. Each patient has a personal physician with whom they have an ongoing care relationship. This physician works with a team who collectively are responsible for the patient and includes a primary focus on quality and safety of care. Whole person care systems focus on prevention of costly ED visits and hospital stays, increasing one-to-one time with patients, patient-provider communication via alternative methods (secure e-mail and telephone), treating to target (having a tracking system for identifying those not within targets for health, such as depression scores, blood pressure ratings, and body mass index), and identifying those lost to follow-up. Whole person care further includes integration of the Chronic Care Model, a model that engages patients with chronic conditions to become more informed and active self-managers, and does so through a prepared, proactive primary care team and supportive delivery system design. The Joint Principles included an emphasis on the importance of reimbursement for physician care management, which is conducted outside of the office visit, a further benefit to the consumer. Because the medical home model is appropriate for organizations where health care delivery and coverage are combined into a single system, such systems have strong incentives to focus on both greater quality of care and cost of care.

Abstract

Purpose

To identify components of the patient-centered medical home (PCMH) model of care that are associated with lower spending and utilization among Medicare beneficiaries.

Methods

Regression analyses of changes in outcomes for Medicare beneficiaries in practices that engaged in particular PCMH activities compared with beneficiaries in practices that did not. We analyzed claims for 302,719 Medicare fee-for-service beneficiaries linked to PCMH surveys completed by 394 practices in the Centers for Medicare & Medicaid Services’ 8-state Multi-Payer Advanced Primary Care Practice demonstration.

Results

Six activities were associated with lower spending or utilization. Use of a registry to identify and remind patients due for preventive services was associated with all 4 of our outcome measures: total spending was $69.77 less per beneficiary per month (PBPM)(P = 0.00); acute-care hospital spending was $36.62 less PBPM (P = 0.00); there were 6.78 fewer hospital admissions per 1,000 beneficiaries per quarter (P1KBPQ) (P = 0.003); and 11.05 fewer emergency department (ED) visits P1KBPQ (P = 0.05). Using a patient registry for pre-visit planning and clinician reminders was associated with $29.31 lower total spending PBPM (P = 0.05). Engaging patients with chronic conditions in goal setting and action planning was associated with 4.62 fewer hospital admissions P1KBPQ (P = 0.01) and 11.53 fewer ED visits P1KBPQ (P = 0.00). Monitoring patients during hospital stays was associated with $22.06 lower hospital spending PBPM (P = 0.03). Developing referral protocols with commonly referred-to clinicians was associated with 11.62 fewer ED visits P1KBPQ (P = 0.00). Using quality improvement approaches was associated with 13.47 fewer ED visits P1KBPQ (P = 0.00).

Conclusions

Practices seeking to deliver more efficient care may benefit from implementing these 6 activities.

The Promise of Health or Medical Primary Care “Homes”

In recognition of the fact that there are many individuals who have multiple chronic or long-term disorders that require special management and coordination of care, the Affordable Care Act of 2010 in the United States created an optional benefit for US states to establish Health Homes to coordinate care for people who have one or more of these conditions. The health home is not a place, but more a single point of responsibility. These organizations are expected to operate under a “whole-person” philosophy integrating and coordinating all primary, acute, mental health, and long-term services needed to treat the individual. People with severe mental illness are explicitly mentioned in this law, as are chronic conditions including substance abuse, asthma, diabetes, heart disease, obesity, and HIV/AIDS. Comprehensive care management provided by health homes include care coordination, health promotion, comprehensive transitional care/follow-up, patient and family support, and referral to community and social support services. A health home provider can be a physician, a multidisciplinary team of health care professionals, a group practice, a mental health center, a federally qualified health center, a clinic, or a hospital. One can read more about Health Homes at Medicaid.gov (Center for Medicare and Medicaid Services, 2013).

Health homes grew out of the concept of “primary care medical homes,” pioneered by Dr. Jeffrey Brenner of Camden, NJ, and others. As recounted in The New Yorker magazine, he found that a small but significant proportion of the people living in Camden were accounting for much of its medical expenses, using its emergency response services, emergency rooms, and hospital stays. Literally 1 percent of the people were accounting for one-third of the medical expenses incurred there. While a great deal of money was being spent, their care was very poor and uncoordinated, and was resulting in poor quality of life and premature death. He tried a “primary care medical home” approach that supports individuals in learning to manage their own care and ensures that they and their families are fully informed partners in developing integrated, comprehensive care plans. A team of care providers is wholly accountable for a person’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. This team coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Patients experience shorter waiting times, enhanced in-person contact, and 24/7 electronic or telephone access and have alternative methods of communication with their health care practitioners available. The home is also dedicated to quality improvement through the use of health information technology shared among all the providers in the city and county. The model has been replicated throughout the United States.

Although it remains untested in many locales, encouraging research is emerging. An evaluation of 46 such medical homes entitled Benefits of Implementing the Patient-Centered Medical Home: A Review of Cost & Quality Results (Nielsen et al., 2012) found that program participants demonstrated up to 70 percent reductions in emergency room visits, 40 percent lower hospital readmissions, and hundreds of millions of health care dollars saved. Primary care visits more than doubled, diabetes care improved markedly, yet overall costs dropped.

… the findings are clear, consistent, and compelling: Data demonstrates that the “Primary Care Medical Home” improves health outcomes, enhances the patient and provider experience of care, and reduces expensive, unnecessary hospital and emergency department utilization. The results meet the goals of the Institute for Healthcare Improvement’s “Triple Aim” for better health outcomes, better care, and lower costs. (Nielsen et al., 2012, p. 2)

The health or medical home concept holds promise for people with SMI who have comorbid medical disorders.

History

The concept of the “medical home” was first described inStandards of Child Care by theAmerican Academy of Pediatrics (AAP) Council on Pediatrics Practice in 1967. It defined “ideal care” for children with disabilities as a practice that provided care that was accessible, coordinated, family-centered, and culturally effective.

The American Academy of Family Physicians (AAFP) used this concept to expand the characteristics based on discussions defining the future of family medicine. These characteristics described the “personal” medical home, which focused on bringing attention to the importance of continuous, relationship-centered, whole-system, comprehensive care for communities (Martin et al., 2004). In2007, the AAP, AAFP, American College of Physicians (ACP), and American Osteopathic Association (AOA) collaborated to define further the foundational principles of the patient-centered medical home (PCMH;Table 2-1). The goal of the medical home is to emphasize the importance of primary care in maximizing quality of care, health outcomes, and the patient experience, with improved cost efficiency, called “the “triple aim” by theInstitute for Healthcare Improvement (IHI, 2014).

However, the ingredients of the medical home (or “health home”) continue to be defined and modified based on the needs of the clinicians and communities that implement them. These ingredients and how they are delivered are key to the achievement of the lofty goals of the medical home and family medicine in general. This chapter discusses the most important ingredients for the medical home and the actions that the family physician can take to create one.

Future

The Patient Protection and Affordable Care Act of 2010 includes the “medical home” model of care delivery. Initially introduced in 1967 by the American Academy of Pediatrics, the patient-centered medical home (PCMH) is an interdisciplinary care approach guided directly by values and preferences of patients and their families. Given their training in active listening and understanding of both verbal and nonverbal communication behavior, clinical psychologists can ensure patient-centered orientation and sustained focus on the patient’s own perceptions of illness and health. This includes satisfaction with care, disease-specific education, behavioral strategies for effective self-management, treatment adherence, and management of depression and anxiety, among other goals (McDaniel & Fogarty, 2009).

Behavioral emphasis is core to effective management of most chronic diseases, particularly the multimorbidity common in older age. Health psychologists have adapted readily to the PCMH model, targeting “patient goals” and holistic care of the person, rather than focusing solely on disease-specific interventions (Kearney et al., 2014). Perhaps nowhere are effective communication and care of the “whole person” more important than in geriatrics.

In addition, psychologists can enhance collaboration and mutual understanding between members of the health care team, patients, patients’ family members and other support systems, throughout the diagnosis and treatment process (McDaniel & Fogarty, 2009). In some health care delivery systems, such as the Veterans Health Administration (VHA), the role of clinical psychologists in biopsychosocial patient care is already standard (Kearney et al., 2014). In 2007, for example, the VHA initiated collaborative care management via primary care mental health implementation. In fact, the VHA has mandated the presence of clinical psychologists on integrated health care teams throughout their hospitals (Zeiss & Karlin, 2008), including Patient Aligned Care Teams (PACT), the VHA version of the PCMH (Kearney, Post, Zeiss, Goldstein, & Dundon, 2011). This is even more notable in primary care, where psychologist offices are intentionally co-located (i.e., same hallway) with primary care physicians and nurse practitioners to facilitate warm handoffs, nonfragmented communication, and patient follow-up, all while minimizing possible stigma due to separation of “mental” health.

Quality of health care communication is essential to maximizing a therapeutic relationship with older patients. Mutual collaboration fosters greater patient satisfaction, reduces the risks of nonadherence, improves patient health outcomes, and allows patients to build trusting relationships with their clinicians. Physicians, like psychologists, who effectively express empathy, engage in active listening, and offer practical, comprehensible assistance via transparent, egalitarian communication, can optimize their clinical impact. Through shared decision-making and a collaborative partnership, physicians can assess and manage their older patients’ biomedical and psychosocial needs (Williams et al., 2007). Decades of research have shown this to be a difficult task to accomplish. A concomitant challenge has been integration of clinical psychologists. Integration can help assure implementation of effective communication strategies into everyday practice. Standard roles in both training and care provision will maximize the likelihood of improvement. As life expectancy increases, so will the need for these skills.

Four Key Concepts in Collaborative Care

The Levels of Collaboration Model dovetails with four overarching concepts related to the implementation of mental and behavioral health services within primary care. The Milbank report (Collins, Hewson, Munger, & Wade, 2010) summarizes these concepts as follows:

The patient-centered medical home including: (i) patient tracking and registry functions; (ii) the use of nonphysician staff for care management; (iii) the adoption of evidence-based treatment guidelines; (iv) patient self-management support, (v) screenings, and (vi) referral tracking.

A team of health care professionals to share responsibility for a patient’s care.

Stepped care on a continuum from: (i) basic educational efforts; to (ii) psychoeducational interventions; to (iii) behavioral health interventions provided by highly trained behavioral health care professionals within primary care; to (iv) specialty mental health services.

The four-quadrant clinical integration model in which Quadrant I patients have low mental health and physical health care needs and are served in primary care; Quadrant II patients have high behavioral health and low physical health care needs and are served in specialty behavioral health systems; Quadrant III patients have high physical health care needs and low behavioral ones and are served in primary care and/or medical specialty systems; and Quadrant IV patients have high needs in both categories, requiring a strong collaboration between specialty behavioral health settings and primary and medical specialty care settings. These patients are more likely to have co-occurring disorders in all categories as well as the lack of a stable medical home.

These models of collaborative care and integrated care are the ideal toward which many health care systems now strive. They are also a major focus for health services research in which investigators assess the effectiveness of these models in improving mental and behavioral health care and outcomes. However, many factors remain to be resolved. One core issue is how to provide the mental health and behavioral health specialists who will collaborate with or integrate into primary care. TMH provides one such approach by telecommuting a broad array of specialists across vast expanses of land and diverse communities to help build new models of care. However, this work is in its infancy.

The remainder of this chapter presents some of the current approaches, successes, and challenges in using TMH to provide specialty mental/behavioral health care. While these efforts are not yet fully collaborative nor integrative, they show the way.

Patient-Centered Medical Home

Theoretically complex cases of patients with chronic pain, co-occurring psychiatric disorders that are at high-risk for abuse would be treated in an integrated pain clinic with access to behavioral health and addiction specialists. In practice there is a paucity of these specialty clinics. The majority of these patients are managed in busy primary care practices that lack the needed resources to effectively manage this patient population. The Patient-Centered Medical Home (PCMH) was developed by primary care organizations in 2007 to promote comprehensive primary care that fosters a collaborate relationship between an individual patient and their personal physician, and when appropriate the family and community. The basic principles of PCMH include that each patient has a personal physician directing medical practice through a team, is whole person oriented, provides coordination of care across a healthcare system, ensures quality and safety, promotes enhanced access to services, and reimbursement for PCMH reflects added value. SBIRT has been utilized in this model for substance abuse with promising results. The PCMH model has great potential in managing patients with chronic pain on opioid therapy and reducing the risk of abuse, addiction, and diversion.

Summary

Psychology consultation is an overdue concept whose time has come. By definition, geriatric patients have multiple needs of both mind and body as they age. To treat older adults effectively and safely, medical teams must employ an integrated biopsychosocial care approach. As collaborative care models, such as the patient-centered medical home (Kathol, deGruy, & Rollman, 2014), are implemented nationally (Butler et al., 2008; Miller, Petterson, Burke, Phillips & Green 2014), psychologist integration is increasingly feasible and necessary (Blount, DeGirolamo, & Mariani, 2006). This chapter illustrates that the absence of psychology in standard practice contributes to and perpetuates many long-standing, well-documented gaps in care. In an inadequate and inefficient health care system, appropriate consultation confers benefit to patients, their families, and physicians alike.

8.08.1 Defining Primary Care, Patient Centered Medical Home, and Population Based Approaches

Primary care medical disciplines usually include Family Medicine, Internal Medicine, Pediatrics and, at times, Obstetrics and Gynecology. Each of these disciplines is considered primary care because they meet the criteria of being “… integrated, accessible health care services by clinicians who are accountable for addressing a large majority of health care needs, developing sustained partnerships with patients, and practicing in the context of family and community” (Institute of Medicine, 1994). In recent years, primary care has incorporated the concept of the Patient-Centered Medical Home (PCMH) that is defined as a team-based model that is patient-centered, provides multifaceted resources for personal primary health care, focuses on safety and quality, utilizes a whole-person orientation, engages in care coordination and integration, leads to a personal physician, yields enhanced access for patients, and provides continuity of care and receives payment for added value (Rosenthal, 2008).

IPC combines primary care medical and behavioral health services to address the continuum of issues patients present within primary care, which leads to improved medical care and is cost-effective. Because primary care addresses a diversity of health issues and treats the entire population of patients, it utilizes a population-based model. This model is defined as an approach that focuses on “… the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003). Advancing the health of populations is one of the four key elements in the Institute for Healthcare Improvement's (IHI's) Quadruple Aim.