By David W. Bauer, M.D.
When is a patient-centered medical home not a patient-centered medical home? In my practice, the answer is “every day.” In 2009 we received NCQA’s designation as a Level 3 PCMH. To achieve this, our physicians had to document ways in which our patients had enhanced access to our practice, provide examples of how we use evidence-based guidelines to provide quality care, demonstrate the means by which we coordinated care across time and space, and a number of other measures. We do, in fact, do those things every day. What we don’t do, is do all of them for every single patient, every single day.
Consider the analogy of a patient with diabetes whose hemoglobin A1c is 6.9. We would say that the patient’s diabetes is well controlled and congratulate the patient. But there are many ways that a patient could achieve this value. One would be to have very little fluctuation of her glucose from hour to hour. Another would be for the patient to drop into the 40s overnight, and climb to 200 immediately after meals. The hemoglobin A1c is an average, and doesn’t factor in variation. For years, decreasing variation has been the mantra of those working to improve quality, increase efficiency, and decrease medical errors in the hospital setting. As we migrate toward a new model of health care in this country—the PCMH—it would be valuable to embrace this concept in our offices as well.
In the portions of our practice where we have fully implemented a PCMH model, we can point to positive outcomes. Several years ago we created a primary care behavioral health program. In this physician-led, team-based approach to treating depression and anxiety in the family physician’s office, we have outcomes that exceed those reported in the literature. The physician identifies patients with depression and/or anxiety through the use of standardized instruments, and implements whatever pharmacologic therapy is appropriate. He or she also introduces the patient to our care manager, who meets with the patient (by e-mail, phone, or in person) weekly. This allows the care manager to identify the patient who is troubled by side effects of medication, whose depression is worsening, who has a new stressor, etc. That information is given back to the physician, who can then intervene quickly. Both the physician and care manager interact with a psychologist, and we also pay for a few hours a week of a psychiatrist’s time for consultation on the more challenging patients. Using objective measures of depression in a team-based model of care collected over a three-year period, our statistics show 39 percent of patients are in full clinical remission, and 50 percent had at least a 50 percent drop in their symptom score after 10 weeks of this model of care. This is twice the rate generally seen in the literature.
We apply the principles of a PCMH to other aspects of our practice as well. We do team-based care for patients with diabetes (physician, Pharm.D., and dietician team), osteoporosis (physician, nurse, and dietician), pregnant women who are obese (obstetrician, sports medicine physician, dietician, and local gym). All patients benefit from our advanced electronic medical record system, our extended office hours (patients have access to at least one of our physicians 79 hours a week), open access, etc. So, in that sense, we offer aspects of the PCMH to each patient.
But, what about the patient with diabetes whose ophthalmologist never sends his notes (despite pleas from the patient and me), so I never can determine if the patient has retinopathy? What about the patient who could benefit from a visit with our dietician, but whose insurance will not cover the visit since the patient does not yet have diabetes? I have let those patients down. I haven’t lived up to the promise of a PCMH to them.
What are we to do? How can we reduce variation? How can we deliver on the huge promise and potential that a true medical home embodies? The answer, like the problem, is going to be complex and multifactorial. Clearly, the universal use of robust EMRs is an absolute necessity. So are local and regional health information exchanges. We need to rethink the time-honored model of the office visit in which the physician extracts a history from the patient. The technology exists today to allow patients to enter portions of their history themselves. Not only is this a more effective use of the limited face-to-face time of most office visits, but it makes the patient an active participant in his or her care—a cornerstone of the PCMH.
Finally, in order to deliver on our promise we will have to share resources. The vast majority of family doctors in this state could not afford to have a full-time dietician, patient educator, patient navigator, therapist, etc. But, it is possible for practices within a geographic cluster to band together to support such team members.
Patient-centered medical homes will transform the care of our patients. The promise is there. The principles are there. And, the practices are there—more and more family physicians’ practices are receiving the PCMH designation. But, so far we have done the easy part. The harder part—being a medical home for every patient every day—is going to take more than a seal from NCQA. The evolutionary changes implemented need to serve as a springboard for revolutionary ones. It is only at that point that all of us can become what we want to be—a true medical home for every single patient, every single day.
David W. Bauer, M.D., practices family medicine at Physicians at Sugar Creek, and is the residency program director at Memorial Family Medicine Residency Program in Sugar Land, Texas.