Catalyzing Practice Transformation Guided by the Patient Centered Medical Home Model

November 29, 2010

The Patient Centered Medical Home Model (PCMH) generates much discussion in health care circles. PCMH demonstration projects are widespread, accreditation organizations are developing and implementing certification programs for PCMH-based practices, and payers – including the federal government – are exploring new reimbursement policies to support medical home-based care.

There is a sense of urgency about implementing medical home capabilities. Yet many people express the concern that all of this is happening in advance of having a clear definition of a medical home or what the PCMH model actually means. Others say, “I’ve been providing a medical home to my patients since I started my practice. There’s nothing new here. This is just creating extra work for no purpose.”

I’m a bit surprised when I hear these comments and concerns. While multiple organizations have articulated PCMH definitions, the essential elements are always the same. And the sources of the ideas, which are very firmly grounded in common sense, are also identical.

In the 1960s, the pediatric community began describing the need for a medical “home” to identify needs and coordinate care for children with complex, chronic illness. These concepts informed the thinking of people at the MacColl Institute who described the Chronic Care Model, broadening the reach of these ideas to encompass all patients with chronic illness.

The Advanced Medical Home model was described by the American College of Physicians (ACP), expanding the scope further by applying the same principles to all patients, including those at risk for future illness and for whom preventive clinical services are indicated. The PCMH model was a direct outgrowth of the Advanced Medical Home model, representing a more refined articulation of the concepts which undergird all of these models. A summary statement from the ACP describes the model as a:

“…team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.”

A foundational concept is that the care be relationship based, involving an active partnership between caregivers and patients. The patient takes an activated role, owning the responsibility to identify personal health goals, work with the care-giving team in developing treatment plans, and actively engage in health behaviors, self-care, and health care seeking behaviors that advance his or her goals. The medical home team is responsible for assuring that care is coordinated across settings of care (e.g., specialists, ED, hospital, other facility) and over time.

While this vision is consistent with what most health care providers hope they can offer their patients, the scope of responsibility, level of engagement with patients, and systems needed to fulfill the vision go well beyond “what we’ve always done for our patients.”

An extension of the responsibility to coordinate care focuses on both the care patients receive during health care visits and the follow up on decisions and plans made at those visits. It also includes proactively identifying the needs of a population of patients, including their preventive and curative needs, and reaching out to people between visits to catalyze action to meet those needs.

The challenge isn’t so much about defining or describing the vision, but rather implementing the information systems and care processes necessary to achieve it and expanding access to medical home-based care.

There are no ruby slippers. You can’t click your heels three times and have a medical home. Simply paying providers to offer medical home-based care, hoping they do so, and then examining whether such payments yield better outcomes is a strategy which isn’t grounded in reality.

It is yeoman’s work to transform clinic practices from their current, acute-care focused, fragmented state and incorporate new systems and processes designed to reliably achieve the goals that flow from the PCMH vision for an entire community of patients.

The required capabilities include, for example, comprehensive patient registries to identify and track the needs of individual patients, manage the needs of a population of patients, and support performance measurement used in the process of continual self-assessment and practice improvement.

They also include modern information systems and team-based care management processes designed to meet the needs of patients with chronic illness. Achieving integration of these clinical systems and processes across medical home-based practices, and between those practices and their facility and specialist partners, is an even greater challenge.

This becomes clear when talking to people who are considering transforming clinical systems and clinic processes in an effort to modernize their practices. A common refrain is “I don’t know how to do this. You can’t get there from here.”

The challenge is daunting. For this reason, physician organizations in Michigan, in partnership with Blue Cross Blue Shield of Michigan, have created regional learning collaboratives designed to train physician organization leaders and staff in the workings of the PCMH model and in change management facilitation techniques so they can incorporate sophisticated process re-engineering skills into their core business. These efforts have catapulted physicians’ practices over the usual barriers to change and helped them incorporate new information systems and care processes, achieving improved efficiencies while doing so.

As evidence of this impact, PMCH-based practices in Michigan have already demonstrated improvements in access to primary care and reductions in the use of emergency department and inpatient services for chronic conditions. This work is not for the faint of heart, but can be transformative when practice teams are empowered to take it on.

Payers and purchasers, and the community in general, will see a much better return on their investments in the long run if they devote attention and resources to catalyzing and supporting provider organizations in their efforts to transform their office practices and integrate them into a system shared by their community of caregivers guided by the PCMH model.


David Share serves as Executive Medical Director, Health Care Quality, at Blue Cross Blue Shield of Michigan. Dr. Share also is the Medical Director of The Corner Health Center in Ypsilanti, a community-based health center for teenagers and their children, serving in this role since 1981. Dr. Share serves on the board of directors of the Michigan State Medical Society (MSMS), where he chairs the Committee on Michigan’s Public Health and the MSMS Task Force on the Future of Medicine.

Dr. Share is a key advisor to CHRT on many of its research and demonstration projects. He will be speaking about Blue Cross Blue Shield of Michigan’s PCMH implementation at CHRT’s December 2, 2010 symposium, Patient Centered Medical Home: Obstacles and Opportunities.