By Debra Wood, RN, contributor
March 5, 2014 - Strengthening primary care through more patient engagement and coordination, the patient-centered medical home (PCMH) model offers great opportunities for nurses and has gained prominence as a way to improve quality while curbing costs. Yet recent studies show mixed results and a model that continues to evolve.
Mona Sweeney, RN, said the promise of medical homes is improving quality and satisfaction while reducing cost.
“The promise is in the triple aim,” said Mona Sweeney, RN, assistant director of accreditation services at the Accreditation Association for Ambulatory Health Care, which has conducted onsite surveys and accredited 358 medical homes, including nurse-led PCMHs. “It’s delivery of care designed to decrease cost, increase satisfaction, and more importantly, No. 1, increase the quality and health of the population.”
PCMHs focus on the patients’ needs, preventing problems, answering their questions and helping the patients develop a plan to address their concerns.
“It’s a collaborative partnership,” said Sweeney, who indicated opportunities exist for nurses, because of the medical home’s team approach to care and the need for care coordination, particularly for chronic conditions.
“To get people healthy takes multiple providers,” added Kenneth S. Peterson, PhD, FNP-BC, assistant professor at the University of Massachusetts Graduate School of Nursing in Worcester. He explained that nurses can practice at the highest extent of their license to keep patients healthier.
Chakina Brunson-Porter, MSN, RN, CPNP, expects more clinicians will move to the PCMH model as the number of patients with chronic conditions and comorbidities increases.
“The medical home is a great approach to care and utilizing providers--physicians and nurse practitioners,” said Chakina Brunson-Porter, MSN, RN, CPNP, a pediatric nurse practitioner in the medical home program at La Rabida Children’s Hospital in Chicago. “Nurses have unique opportunity because of the medical home. It opens up a new model. Nurses are not only patient advocates but case managers and liaisons to external agencies, and that is beneficial in keeping up the continuity of care.”
Myrla Balderas, RN, BSN, a care coordinator at The Center for Children and Women at Texas Children’s, a PCMH in Houston, called it an awesome place to work and praised the comprehensive care provided.
“Working in a medical home enhances every nurse’s ability to have a broader scope of care,” Balderas said.
PCMHs are not new. The American Academy of Pediatrics described a medical home primary care model in 1967. Later other medical societies embraced the concept, and several organizations began accreditation programs.
The Institute of Medicine called for more patient-centered care around 2000, Peterson said. Enacted in 2010, the Affordable Care Act offered support for medical home pilots.
The 2014 annual report from the Patient-Centered Primary Care Collaborative (PCPCC) highlighted PCHM outcomes reported from August 2012 to December 2013. Among peer-reviewed/academic papers it found a 61 percent reduction in cost, 61 percent fewer emergency department visits, 31 percent fewer inpatient admissions, a 31 percent improvement in access, a 31 percent increase in preventive services and a 23 percent improvement in satisfaction, among other positive findings.
However, a study of PCMHs in Southeastern Pennsylvania by researchers at the nonprofit research organization RAND Corp. in Boston found the medical home pilot did not show a reduction in patients’ use of hospitals or emergency departments, or total costs of medical care, when compared with traditional medical practices. They reported in the Journal of the American Medical Association (JAMA) not detecting improvements on the quality measures that assessed asthma care, cancer screening and control of diabetes. The only quality measure with significant improvement was monitoring for kidney disease among patients with diabetes.
“The takeaway of this study is we are very much in the experimental stage in understanding how to improve primary care practices and turn them into the kinds of medical homes that will deliver on the medical home model, and we don’t have the answer yet,” said lead author Mark W. Friedberg, MD, MPP, a scientist at RAND.
“It is possible that the pilot we evaluated had some, but not all, of the ingredients necessary to produce broad improvements in quality and efficiency,” Friedberg added. “Findings from this evaluation and others should help refine the medical home model.”
National Committee for Quality Assurance (NCQA) spokesperson Apoorva Stull responded that the JAMA study is based on outdated PCMH standards. NCQA updated its standards in 2011 and will update them again this month, with an emphasis on team-based care, care management for high-need populations, and an alignment of quality improvement activities.
“In effect, we have already--twice--done the ‘further refinement’ the study recommends,” Stull said. “Our standards will continue to evolve.”
PCPCC CEO Marci Nielsen, PhD, MPH, pointed out that the medical homes in the JAMA study lacked some key features of a medical home.
Among those features are improved access, such as weekend and evening hours, which the pilot did not offer.
Myrla Balderas, RN, BSN, enjoys working in a medical home as a care coordinator.
Balderas credits the Center for Children and Women’s extended hours, 7 a.m. until 11 p.m., with reducing emergency department visits.
“We are able to see walk-in patients,” Balderas said.
The JAMA paper did not mention care coordination. However, Friedberg said the pilot medical homes increased case management from 10 percent at the start of the study to 93 percent at the end.
“Perhaps they did not include where we see most of the cost savings, looking at chronic care,” Sweeney said. “Those are the patients who will benefit the most.”
The pilot medical homes in the JAMA study also did not have financial incentives, which could have contributed to the results.
Additionally, it is possible the control group practices also were focusing on improving quality outcomes, Friedberg said. But the researchers did not receive much information from the traditional practices.
Bruce A. MacLeod MD, president of the Pennsylvania Medical Society, urged people not to jump to any conclusions or to give up on medical homes. He encourages further research, which is underway in the state.
“We need to pull out the study lessons, pay attention to what they are and go forward,” Sweeney said.
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