In support of The Commonwealth Fund’s efforts to promote delivery system improvement and innovation, the Program on Patient-Centered Coordinated Care sponsors activities aimed at improving the quality of primary health care in the United States, including efforts to make care more centered around the needs and preferences of patients and their families. To achieve this mission, the program makes grants to:
As defined by the Institute of Medicine, patient-centered care is “health care that establishes a partnership among practitioners, patients, and their families...to ensure that decisions respect patients’ needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care.”
There is substantial evidence that health systems built upon a strong primary care foundation deliver higher-quality, lower-cost care overall and greater equity in health outcomes. Research also suggests that patient-centered primary care is best delivered in a medical home—a physician practice or health center that offers enhanced access to clinicians, coordinates all of a patient’s health care services, and engages in continuous quality improvement.
Promoting and Evaluating the Patient-Centered Medical Home
In April 2008, The Commonwealth Fund launched the five-year Safety Net Medical Home Initiative to support the transformation of primary care clinics serving low-income and uninsured people into patient-centered medical homes. Led by Jonathan Sugarman, M.D., president and CEO of Qualis Health, a nonprofit quality improvement organization based in Seattle, and Edward Wagner, M.D., of the MacColl Institute for Healthcare Innovation, the initiative involves 65 clinics in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. The Qualis/MacColl team provides technical assistance to local quality improvement organizations that, in turn, help the clinics achieve benchmark levels of performance in quality and efficiency, patient experience, and clinical staff experience. Eight foundations have joined the Fund in support of the initiative.
To help extend the reach and impact of the demonstration, the project team is developing an online curriculum for quality improvement coaches who are supporting the efforts of the nation’s 1,300 community health centers to become effective medical homes. The Safety Net Medical Home Initiative is serving as a blueprint for the Center for Medicare and Medicaid Innovation’s three-year medical home demonstration for federally qualified health centers, which provides technical assistance and enhanced payment to over 500 health centers in 44 states.
Under another Fund grant, Marshall Chin, M.D., and a team of researchers at the University of Chicago are evaluating whether clinics participating in the Qualis/MacColl initiative are in fact able to make the changes necessary to function as medical homes. The team is also assessing the extent to which sites that are getting technical assistance and enhanced reimbursement for providing medical home services improve their performance on measures of quality, efficiency, patient experience, and clinician or staff satisfaction. While data on patient impact is not yet available, baseline results of physician and clinic staff surveys show that when a safety-net clinic has more core medical home features—systems for tracking patients with unmet needs, personnel to help patients manage their chronic conditions, resources for quality improvement—the physician and clinic staff report higher morale and greater satisfaction with their jobs.
The Commonwealth Fund has supported 10 evaluations of medical home demonstrations. To align evaluation methods, share best practices, and exchange information on ways to improve evaluation designs, the Fund in 2008 established the Patient-Centered Medical Home Evaluators’ Collaborative, co-chaired by Meredith Rosenthal, Ph.D., of the Harvard School of Public Health and the Fund’s Melinda Abrams. A key objective of the collaborative is to reach consensus on a core set of standardized measures in each of the main areas under investigation, such as use of health services, cost savings, clinical quality, patient experience, and clinic staff experience. In 2012, the evaluators’ collaborative announced recommendations for standardized measures of cost, utilization, and technical quality outcomes in medical home evaluations. The Centers for Medicare and Medicaid Services has encouraged its prospective medical home evaluation contractors to use the metrics, described in a Commonwealth Fund issue brief, in their federally funded studies.
Building Capacity for Delivering Patient-Centered Coordinated Care
The Commonwealth Fund is supporting a number of efforts to help guide implementation of the medical home model’s defining features, including team-based care, care management for high-risk patients, availability of after-hours care, and care coordination. For example, Timothy Ferris, M.D., and Clemens Hong, M.D., of Massachusetts General Hospital are comparing primary care–based care management programs that have been shown to improve quality of care and health outcomes for high-risk patients. The study will compare the programs on operational features, such as training of care manager, panel size, patient eligibility criteria, and use of information technology to monitor care. The Fund also is supporting Lawrence Casalino, M.D., Ph.D., of Weill Cornell Medical College to assess the value of e-mail as a means of communication between patients and providers.
To gain a better understanding of what facilitates the spread of patient-centered medical homes, the Fund is supporting researchers at Pennsylvania’s Geisinger Health System to examine how its medical home program has reduced costly hospital admissions and readmissions. In particular, the study team is looking at ways to streamline and standardize the implementation of medical homes in primary care sites.
Helping Smaller Physician Practices Share Patient Care Resources
Because Because of their limited resources and capacity, small primary care practices often struggle to meet the functional requirements of a patient-centered medical home, which range from providing round-the-clock patient access to using a team approach to chronic disease management. Research has shown, however, that when primary care providers in the same community band together to share local resources or expertise—such as care coordinators or quality improvement coaches—they enhance their capacity to provide care and improve their performance.
With Commonwealth Fund support, the University of Montana’s Stephen Seninger, Ph.D., is evaluating a statewide shared care management program where nurses working out of the local community health center provide support exclusively to high-risk Medicaid patients served by private, community-based physician practices in Montana. Dr. Seninger is examining the impact of the program on cost and quality of care as well as its viability in other rural communities. Under another Fund grant, Tara Bishop, M.D., at Weill Cornell Medical College is evaluating a pilot program in New York City that enables safety-net practices to share the services of a patient-panel manager, who helps ensure that patients receive recommended routine services and chronic disease care.
Improving Policy and Financing to Promote Patient-Centered Care
Forty-two states are developing patient-centered medical home programs for their Medicaid and Children’s Health Insurance Program enrollees. With Commonwealth Fund support, the National Academy for State Health Policy (NASHP) has been working with state Medicaid officials and other key stakeholders to ensure that beneficiaries have access to a medical home. Since 2011, NASHP has worked with 23 states to strengthen, expand, and sustain medical home initiatives, providing guidance on payment models, evaluation metrics, and technical assistance approaches. In a Health Affairs article (Nov. 2012), NASHP’s Mary Takach reviewed the variety of reforms taking shape, including new fee structures that enable physician practices to be reimbursed for the care management services they provide; support for smaller practices to share the services of registered nurses, behavioral health specialists, and other health professionals; and the alignment of payment with quality standards. For more information about states’ efforts to promote medical homes, see the Commonwealth Fund/NASHP report Building Medical Homes: Lessons from Eight States with Emerging Programs and NASHP’s interactive medical home map.
To identify the most effective way to reimburse primary care providers that attain high performance, the Pennsylvania Chronic Care Initiative—the most extensive multipayer medical home demonstration program in the nation—is testing four different methods for financially rewarding primary care sites that function as medical homes. A Fund-supported team of RAND and Harvard University researchers headed by Mark W. Friedberg, M.D., is assessing the differential impact of these payment approaches—from per-member per-month care management fees to shared savings—on health care utilization, efficiency, cost, and quality of care.
The Affordable Care Act features a number of provisions intended to strengthen primary care in the United States. To aid successful implementation of these reform efforts, The Commonwealth Fund’s Program on Patient-Centered Coordinated Care will support projects in a number of areas.
Making medical homes successful. To spread medical homes, health system leaders, clinicians, and policymakers need information on the factors that lead to improved quality of care, greater efficiency, and lower costs. Future work will need to help providers implement the medical homes in ways that are sustainable, economical, and patient-centered.
Resource-sharing. Owing to their limited resources, smaller independent physician practices typically are unable to deliver the breadth of services and engage in the range of quality improvement activities more commonly provided by larger practices. The Fund is supporting research into models for sharing clinical support services and health information systems, so that practices are able to provide coordinated care, after-hours appointments, and other services expected from medical homes.
Policy implementation. As the Affordable Care Act’s primary care provisions take effect, a Fund priority will be to synthesize and disseminate findings from the many medical home evaluations that are in progress for local, state, and federal policymakers.
Integrating the medical home with the “medical neighborhood.” Commonwealth Fund support is aiding efforts to understanding how medical homes can integrate and partner with the other providers in their community—for example, specialists, hospitals, and mental health care providers in both safety-net and commercial settings—to ensure high-quality, efficient care.