This piece first appeared in the Health Affairs Blog on April 26, 2011.

The patient-centered medical home has grabbed the limelight as a new model of health care that offers an alternative to fragmented, impersonal, and wasteful care that has become the norm throughout much of the U.S. The PCMH model promises each patient a primary care provider leading an interdisciplinary care team, with the intent of delivering seamless care across services and settings, keeping the patient at the center. A substantial evidence base is building for improved quality, patient experience, and reduced health care costs associated with medical homes. (1)

One of the key features of medical homes is a focus on coordinated, collaborative, continuous care. Primary care practitioners, specialists, nurses, and other health care professionals are expected to work closely together in “flat” teams that discourage medical hierarchy and encourage cooperation, collaboration, and team work. This team is supposed to include the patient as an active participant in health care decision making. After all, care in the medical home is patient centered … or is it?

Patient-Centered Care Teams

PCMHs can take a variety of organizational arrangements: nested within integrated health systems like Kaiser and Geisinger; operating across providers through physician and hospital organizations; in the emerging accountable care organizations called out by the Affordable Care Act; leveraging networks of independent providers; based in community health centers, clinics and other safety net providers; and more.

Integrated care delivered by interdisciplinary teams is a core concept, but who leads and who is included on the team can vary considerably. While the PCMH opens the door to bring new players and professional disciplines to the patient care team, the division of labor and responsibility has been a source of considerable angst, often pitting professional groups at odds over who is in charge. Physicians may assume dominion as primary care team leaders, but nurse leaders, in particular, have been fast to question this role.

Sometimes physicians will lead, but not always. New roles and identities for physicians and other health professionals that require new competencies that emphasize collaborative practice styles are emerging. Other health professionals are also queued up to lead these interdisciplinary, interprofessional teams. Nurse practitioners are experienced primary care coordinators and team leaders, and health reform legislation expands these roles. Advance practice registered nurses are called out to increase their roles providing primary and preventive care, chronic care management and care coordination, and to step up as managers of community health centers. Physician assistants, pharmacists, and community-based providers are also ready collaborators for patient-centered care teams. They are typically less costly and more available than physicians, and important contributors to the primary care workforce.

As the professionals sort out roles and responsibilities, the patient is at the center of this team—but where?

Patient-Centered Care Delivery

Patients have not been all that happy with the PCMH, according to early research. Pauline Chen’s NYT article (2) brought patients’ dissatisfaction with the PCMH to the public discussion last July 2010. Citing reports from 36 practices participating in the PCMH National Demonstration Project, (3) she notes that patients felt disoriented, displaced as team care replaced the one-to-one patient-doctor interactions. The article asserts that patient satisfaction fell because few patients were aware of or involved with the changes going on around them.

Patients and providers don’t always see eye to eye, and tend to value different aspects of relationship in the medical encounter. It’s the patient-centered medical home and the patient isn’t included in managing and running it. What is to like?

Consumer preferences are changing. Sure, some patients will prefer the traditional one-on-one relationships with their physicians that are increasingly hard to find. Some patients will expect to play an active role in their health care, engage with transparency in their relationships with primary care practitioners, and will rely on their health information savvy thanks to the Internet, social networking, and other new media. These individuals will manage their health care as proactive, engaged consumers—not as patients to be acted upon. They want to work with their providers, and use them as consultants to support our personal health and health care decision making.

These consumers also want choice. In a recent article in the American Journal of Managed Care (4), author Tim Hoff suggests that many patients, especially younger and healthier ones, may not find the PCMH model an attractive one. Other forms of health care delivery, e.g., retail clinics staffed by non-physician providers, might better suit some consumers. Still other consumers will choose a combination of self-care and professional consultation as a cornerstone of their health care.

Setting the Ground Rules for Patient Centeredness

The PCMH is not one-size-fits-all, and neither are the patients or providers who live, work and play within its walls. PCMH models are new, diverse, dynamic, and evolving. We need to understand them, work with them, and design them from blueprints that meet patients’ needs. Ideally, the PCMH helps to empower patients who can participate fully in their care—and places the patient at the center as part of the care team. What new skills are needed, and how can we prepare competent patients in the PCMH? Patients do have responsibilities: meeting appointments and follow up visits, filling and refilling prescriptions, communicating frankly about health concerns, and more. Notably, many will fall short, and disparities will advantage or disadvantage specific patient groups. Low-income, culturally diverse and other special populations will likely require enabling support to meet their patient responsibilities in the PCMH.

Experience shows that health care professionals can play better with others on collaborative, interprofessional teams when they understand and appreciate the shifting roles and how they fit together in a patient-centered medical home. Groups like the Interprofessional Education Collaborative, including representatives of medical, dental, nursing, pharmacy, and other health professions, are tackling PCMH practice dynamics head on, identifying competencies and training goals for team-based care. These are the new rules for collaborative, interdisciplinary care coordination.

Just as patients have responsibilities, providers can support the patient-provider relationship by providing basic information to navigate the encounter, e.g., how to make appointments and seek care, outlining insurance and payment arrangements, and laying out the conditions under which diagnostic testing is conducted, among others.
The Center for Advancing Health proposes Rules and Terms of Engagement (5) that make explicit previously assumed expectations about responsibilities of both patients and providers, and a pact describing a process for mutual decision making in the PCMH. It sounds simple, though speaking up to one’s physician or other primary care practitioner admittedly can be intimidating. But it’s a start.

Location, Location, Location

In the end, patient-centered care is about respect, engagement and choice. Respect among providers on the interdisciplinary care teams, respect among patients and providers, and a willingness for all to engage in truly shared decision making. In shared decision making we have better outcomes, less waste and more affordable care.

The beauty of the PCMH lies in its flexibility, its potential, and its dynamic nature as a tool for primary care transformation. It is as much a process as a foundation and structure for care delivery. We are reminded, “… it is more about learning how to be a learning organization that creates an emergent future than it is learning from experts … the level of change needed is daunting and requires tremendous motivation of all practice participants, defining new roles, understanding the local landscape, and paying attention to multiple relationships.”(6)

The patient’s in the center, somewhere, in the PCMH. Where? When established players complain, THAT’s where to start looking. That’s where we’ll find patient centeredness. It means change is coming, and sometimes change is a good thing.

References

• (1) Grumbach, K., & Grundy, P. (2010, November 16). Outcomes of implementing patient-centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. Washington, DC: Patient-Centered Primary Care Collaborative. Retrieved from http://www.pcpcc.net/content/pcmh-outcome-evidence-quality.
• (2) Chen, P. (2010, July 15). Putting patients at the center of the medical home. The New York Times. Retrieved from http://www.nytimes.com/2010/07/15/health/15chen.html?_r=2&src=tptw.
• (3) Crabtree, B. F., Nutting, P. A., Miller, W. L., Stange, K. C., Stewart, E. E., & Jaén, C. R. (2010). Summary of the National Demonstration Project and recommendations for the Patient-Centered Medical Home. Annals of Family Medicine, 8(Suppl 1), S80–S90. Retrieved from http://www.annfammed.org/cgi/reprint/8/Suppl_1/S80.
• (4) Hoff, T. (2010, June 4). The shaky foundation of the Patient-Centered Medical Home. American Journal of Managed Care.
• (5) Gruman, J., Jeffress, D., Edgman-Levitan, S., Simmons, L., & Kormos, W. (2008). Supporting patient engagement in the Patient-Centered Medical Home. Washington, DC: Center for Advancing Health.
• (6) Crabtree, B. F., Nutting, P. A., Miller, W. L., Stange, K. C., Stewart, E. E., & Jaén, C. R. (2010). Summary of the National Demonstration Project and recommendations for the Patient-Centered Medical Home. Annals of Family Medicine, 8(Suppl 1), S80–S90. Retrieved from http://www.annfammed.org/cgi/reprint/8/Suppl_1/S80.

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