Transforming primary care: improving on the medical home model

Department of Health Studies, University of Chicago, Chicago, USAINTRODUCTIONGiven the convergence of exponential spending on healthcare in the US, poor health outcomes relative to othercountries, an aging population, and outdated methods ofdelivering primary care, there is no better time forinstituting a ‘‘disruptive’’ innovation in primary careredesign than the present (Christensen, Bohmer, & Kenagy,2000). In the midst of health reform in the US, the conceptof the patient-centered medical home (PCMH) is garneringsigniﬁcant attention as a potential solution to addressﬁnancial and performance issues (Vincent & Velkoff, 2010). While the model has worthy attributes, including anemphasis on care coordination and patient engagement,recent studies highlight the gaps and limitations in theexisting approaches (Nutting et al., 2009; Rogers, 2008). Some of these gaps and limitations in the traditional PCMHmodel include difﬁculties in accomplishing shared decisionmaking with the patient and health care team, effectivecommunication across services, and offering a broad rangeof health care services.The authors propose an alternative, primary care redesignmodel intended to build on the strengths of the PCMH modeland address some of the current shortcomings in implemen-tation. This alternative model is designed to improve patienthealth and satisfaction, while decreasing costs and may beparticularly effective among the frail elderly.THE PATIENT CENTERED MEDICAL HOME MODELAlthough considered by many to be a new idea, the medicalhome concept was ﬁrst introduced in 1967. A review of theprinciples, standards, position papers, and projects to datereveals several themes required of a PCMH. Basic criteriainclude (a) directly provided services, (b) physiciancoordination of care, (c) patient involvement in planningcare, and (d) collecting, sharing, and monitoring data toimprove care.Limitations in how this model is operationalized havebeen highlighted in recent research (Nutting et al., 2009;Sinsky, Sinksy, Althaus, Tranei, & Thiltgen, 2010). Directlyprovided services in current PCMH models are typicallylimited to primary care and laboratory testing. Second, aPCMH requires new skills for many physicians in carecoordination and management and working in teams withshared decision making. Finally, most PCMH practices dolittle to assess the home and community factors affectingthe patient’s health (American College of Physicians, 2005;Fields, Leshen, & Patel, 2010; Nutting et al., 2009; Rogers,2008). However, recent research ﬁndings suggest that a healthcare system of higher quality at lower cost will require: easyaccess, a wide array of services offered by the primary carefacility, care provided over sustained periods of time, carethat is coordinated amongst various disciplines/services,and patient-focused care with an orientation to family andcommunity needs (Fields et al., 2010; Nutting et al., 2009). Although PCMH models are beginning to emerge thataddress some of these requirements, none to date has beenable to incorporate all of these within one model. Theauthors propose an alternative primary care delivery modelthat is consistent with higher quality/lower cost healthsystem research ﬁndings and builds on the strengths of thePCMH model, while striving to overcome its implementa-tion challenges.AN ALTERNATIVE MODEL OF PRIMARY CARECare Plus, an alternative to the traditional PCMH model, isdeﬁned as a ‘‘patient-centered health care home’’ model thatincludes a wide array of directly provided primary care andsupport services, coordination by a community health