No Place Like Home

Watch a Medscape General Medicine video editorial on medical homes by Steve Schoenbaum.

Guest written by Stephen C. Schoenbaum, M.D., M.P.H., Executive Vice President for Programs and Melinda Abrams, M.S., Senior Program Officer, Child Development and Preventive Care and Patient-Centered Care

Imagine that you have a case of acute bronchitis that worsens dramatically over a holiday weekend. How many treatment options would you have, other than the emergency room? According to a recent Fund survey, more than half of U.S. primary care physicians do not offer after-hours care.

So, while Americans may not be familiar with the term "medical home," they know when they don't have one—that is, a primary care practice that provides them with accessible, continuous, and coordinated care. In fact, more than half of Americans report that they have been seeing their doctor for less than five years, and nearly 20 percent of U.S. adults report that their test results or medical records were not available at the time of a scheduled appointment, or that they received conflicting advice.

A medical home is more than just a place; it is a comprehensive approach to providing care. The idea of a medical home is 180 degrees from an emergency room, urgent care facility, or walk-in clinic. In medical home practices, patients develop relationships with their providers and work with them to maintain healthy lifestyles and coordinate preventive and ongoing health services.

In this sense, medical homes are the foundation of patient-centered care, designated by the Institute of Medicine as one of the six aims for the health care system, and defined as care that is respectful of, and responsive to, individual patient preferences, needs, and values.

Origin of Medical Homes
The concept of a medical home began with pediatricians, who see children frequently during their early years and thus have opportunities to provide comprehensive care, including developmental and behavioral services. In 1977, the American Academy of Pediatrics adopted a policy statement which declared that "quality medical care is also best provided when all the child's medical data are together in one place, (a medical home) readily accessible to the responsible physician or physicians."

The Academy has fleshed out this concept over the years. In 2002, it described the concrete attributes of a medical home, for example defining "accessible" care as care that is physically and financially within reach of patients, but which is also facilitated by effective patient–provider communication. "Comprehensive" care, they maintained, should extend beyond basic medical care to include educational, developmental, psychosocial, and other individual needs.

The Academy has already pilot-tested and evaluated the medical home model for children with special health care needs in several practices around the country. Findings, published in a 2004 Pediatrics supplement, revealed that parents of children who have a medical home report significantly less delayed or forgone care, significantly fewer unmet health care needs, and significantly fewer unmet needs for family support services. Today, the Academy is calling for medical homes for all children, not just those with special needs.

Not Just for Kids
Many experts argue that medical homes are important for all patients, not just children and adolescents. As part of broader quality improvement efforts, medical homes could ensure the provision of appropriate preventive services, help patients manage their chronic conditions, and reduce spending on emergency or other acute care. Nurses would play central roles, working with primary care physicians to develop disease management programs for patients with chronic illness and provide support for all patients in their efforts to live healthy, productive lives.

Yet, there are significant challenges to realizing the promise of medical homes. Many of the services called for in true medical homes, such as linking patients with needed community services, providing consultations via e-mails, and consulting or coordinating care with other physicians, are not usually paid for directly by insurers. And, for a variety of reasons including lack of insurance coverage, 13 percent of Americans did not have a usual source of care in 2005. Frequent job changes or relocations also contribute to people moving in and out of different practices. Studies show that those without a primary care provider are more likely to have unmet needs for care, more hospitalizations, and higher costs of care, and they are less likely to keep doctor appointments and receive preventive care services.

What's more, the number of American medical graduates entering primary care fields—particularly family medicine and general internal medicine—has dropped precipitously. Creating medical homes would require changes in training. Learning to coordinate care and manage a practice are not prominent subjects in physician training. Nurses and physicians' assistants might extend the nation's capacity to deliver primary care services, but face similar challenges with respect to reimbursement.

One new promising piece of Medicare legislation, however, might alleviate reimbursement concerns for primary care practices. The bill, which has been referred to several House committees, calls for a Medicare Medical Home Demonstration Project that will offer management fees to clinicians who serve as personal physicians and incentive payments to physicians in practices that provide medical home services.

Toward Patient-Centered Care
The Fund's Commission on a High Performance Health System has emphasized the importance of a patient-centered, primary-care oriented health care system. And in a 2005 article in the Journal of General Internal Medicine, Fund President Karen Davis and colleagues outlined the seven attributes of patient-centered primary care: superb access to care; patient engagement in care; clinical information systems that support high-quality care, practice-based learning, and quality improvement; care coordination; integrated and comprehensive team care; routine patient feedback to doctors; and publicly available information. The medical home, the authors say, would be an important first step toward creating a patient-centered care system.

Through its new Patient-Centered Primary Care Initiative, the Fund is supporting efforts that will ultimately measure how well medical homes can, in fact, affect patient experience, health outcomes, and health system performance.

In one Fund project, Sarah H. Scholle, Dr.P.H., assistant vice president for research and analysis at the National Committee for Quality Assurance, is developing a set of measures to evaluate the patient-centeredness of care provided in physician offices. For example, Scholle has created specific measures on access to care that focus on scheduling and coordinating visits, providing urgent care advice, e-mail and online communication, and language services.

Research has found that minority families are less likely to report that their children have a medical home—even if they have a primary care pediatrician. This suggests that, to provide true medical homes for all patients, health care providers will need to become "culturally competent"—taking into account patient's preferences and values when recommending treatment and providing care.

The American Academy of Family Physicians (AAFP), the nation's largest professional association of primary care doctors, has launched an ambitious project that will attempt to find out. AAFP has created TransforMED, a National Demonstration Project to test whether 36 participating primary care practices can "transform" themselves and, if so, whether the transformed practices will improve care and make primary care practices more welcoming and satisfying to patients.

One of the goals of the new model is to create a medical home. The Fund is contributing to the evaluation of the new model by supporting a survey of patients served by the practices to determine if the demonstration project has affected their access to services and their clinical information, engagement in care decisions, care coordination, and other factors associated with patient-centered care.

Recently, the American College of Physicians (ACP) introduced the concept of an "advanced medical home." In their proposal, primary and specialty care practices could be certified as advanced medical homes if they can show they provide patient-centered care based on the principles of the chronic care model; use evidence-based guidelines; apply appropriate health information technology; and demonstrate the use of "best practices" to meet the needs of patients while being accountable for the quality and value of care provided. The ACP called for changes in reimbursement and coverage policies to support medical homes, as well as new workforce and training approaches.

What Are Your Thoughts?
Research shows that better developed primary care services in other countries such as Denmark, and even in certain regions of the United States, are associated with better patient outcomes and lower costs. Yet, the current U.S. health care system is highly specialty oriented. Do you think this can change? How? We'd like to hear your feedback on this issue and on medical homes generally. Please send an e-mail with your perspective to scs@cmwf.org or mka@cmwf.org. With your permission, we'll plan to publish some of your responses.

Read select reader responses, along with commentary from the authors.


December 2006


Written with the assistance of Martha Hostetter, editorial adviser.

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