Wednesday, November 21, 2012
Organic medical homes (that are gluten-free)
What comes to mind when you hear the term "medical home?" Perhaps you favor the definition put forth by our government (AHRQ):
"The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care."
They go on to describe five functions and attributes that define the medical home:
--quality and safety.
The presence of these five attributes to care should then constitute a medical home, right? It depends on who you get your definition from.
Take, for example, the definition put forth by NCQA, the body responsible for certifying practices as providers of the patient centered medical home:
"NCQA 's Patient-Centered Medical Home (PCMH) 2011 is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time. The NCQA Patient-Centered Medical Home standards strengthen and add to the issues addressed by NCQA's original program.
The patient-centered medical home is 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."
The one-up AHRQ and say that six elements need to be met for recognition as a PCMH:
--enhance access and continuity
--identify and manage patient populations
--plan and manage care
--provide self-care and community support
--track and coordinate care
--measure and improve performance
Perhaps the ACP (of which I am a member) says it best:
"The Patient Centered Medical Home is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand."
It certainly is the simplest definition.
Regardless of definition, the idea of a patient-centered medical home has become very popular in circles pushing for a primary care centered health care reform. My old practice started in the process of certifying for PCMH through the NCQA, and I discovered something: it really isn't that patient-centered. Just like "meaningful use" is not really about using computers in a meaningful way, but instead an exercise to collect data in a way prescribed by a non-clinical body, the PCMH should really be called the "data-centered medical home." It's all about gathering and reporting data in a specified way, taking time and resources away from the thing at the center of care (by any definition): taking good care of patients.
Now, I am not totally against these kinds of programs; I certainly think their origins are driven by good intent. But I am wary of anything that comes in the form of prescription by a non-clinical governing body to define care for humans by other humans. I had to work hard to make meaningful use truly meaningful for my patients, and I anticipate that had I stayed at my old practice, a significant impediment in truly providing a good medical home for my patients would have been our effort toward PCMH certification.
A new idea came to me as I planned for my new practice, a practice that doesn't answer to insurance company requirements or government regulations: I am creating a medical home for my patients. I plan on meeting all the criteria put forth by the AHRQ and the NCQA, but not because I want to get certified or paid more, it just seemed like better care. The difference, however, between my version of the medical home and the "official" version is that mine is grown from the ground up; it is simply better care for my patients. I am growing the medical home "organically," not meaning that I am avoiding pesticides, but that I am allowing good care to grow on its own, rather than to do it by meeting a shape defined by a group of people who neither know nor care for my patients.
How will I make an organic medical home?
Access: My patients will have access to me. They will have my cell phone number, and can access me via secure online messaging or in person.
Personalized care: Each person will have their own personalized care plan ("GPS") that will let them know what care they should have, what they've done, what they are due for, and when care is due in the future.
Continuity: My patients will (in my plan) have a personal health record that will serve as their "official" medical record. Any records from any care from me or any other provider should be contained in a single medical record. I believe that should be the patient record, not one kept at a doctor's office.
Self-care and community support: I will provide resources for my patients to know what care they need. I intend on having an online library of information as well as links to websites I think will help them deal with their problems. I will also have education programs for people with certain conditions (dietitians teaching diabetics how to shop for food, for example) and do group visits to link like-minded patients together.
Track and coordinate care: I see this as my main task. I don't give most of the care, I just help people get hooked up to the resources they need. Online contact will be the main vehicle for this, but I'll use whatever means necessary.
Measure and improve performance: for my patients, the main measures of my performance are time and money. How much time are people spending at specialists, ERs, or in the hospital, and how much money are they spending on their care in total? If I can keep people healthy and away from the system, I will be improving the lives of my patients in both physical and financial ways.
So, I guess I can say I am "going organic" in my approach to the medical home. Perhaps I should also point out that my care will be entirely gluten-free? That could be a huge selling-point, a marketing bonanza.
I must be a genius.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
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