September 1, 2008
Stephen Zuckerman, Robert Berenson
R. A. Berenson, T. Hammons, D. N. Gans et al., "A House Is Not a Home: Keeping Patient at the Center of Practice Redesign," Health Affairs, Sept./Oct. 2008 27(5):1219–30.
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In the Literature
Based on a literature review and interviews with physics, researchers identified ways in which medical homes could address problems facing the health care system, such as reimbursement inequities, and discussed prerequisites for medical home implementation.
The patient-centered medical home (PCMH) has been broadly defined as a practice providing care that is "accessible, continuous, comprehensive and coordinated and delivered in the context of family and community." While the definition is widely accepted, advocates of the PCMH model may have different expectations and emphases. Broad consensus on what medical homes can reasonably expect to accomplish and how they can be best supported will be necessary for wider adoption.
A 2020 Vision of Patient-Centered Primary Care
." Bridges to Excellence, the National Committee for Quality Assurance, and other organizations initiated programs to advance PCMH activities.
Improving Care, Controlling Costs
The Bottom Line
PCMH may be a transformative innovation—for some practices now, but for many others only in the long run. Proponents of the model should be careful not to alienate physicians by overemphasizing the adoption of more challenging elements, like EHRs, and by not focusing on crucial aspects of patient-centered care.A seven-country survey found that having an accessible medical home that helps coordinate care is associated with more positive patient experiences.Much of the growth in recent health care spending is associated with patients with multiple chronic conditions. Primary-care-based disease management models that highlight multidisciplinary teams and informed patients have shown success in improving care and reducing costs.Recent medical school graduates have expressed little interest in primary care careers, partly due to relatively low reimbursement rates. The PCMH model may help to recognize and support primary care activities.Busy physicians—particularly those in small practices—operate under tremendous time constraints and resist changes that initially take away from time with patients.Managing resources will be challenging for small and solo practices, even if they have the will to adopt the PCMH model. For instance, the per-patient costs of implementing an EHR system are higher for smaller practices; similarly, a small practice may not have enough diabetic patients, for example, to warrant adding a diabetes educator to staff.Implementation and operation of PCMHs requires management capability and physician leadership, as well as the capacity to develop processes and IT systems. These conditions will present challenges for any practice, regardless of size.