It seems like the term “Patient-Centered Medical Home,” or PCMH, has been getting a lot of attention lately, particularly in discussions related to value-based care. For that reason, as the first installment in my new “What Is?” series, I’d like to focus on this concept.
So what is a PCMH?
According to the National Committee for Quality Assurance, a PCMH is a model of care where participants emphasize “better relationships between patients and their clinical care teams” with care coordination being an important facet of the program.
To put the concept in historical context, the “Joint Principles” formally establishing the concept of PCMHs back in 2007 was put forward as part of a collaboration between the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA), which envisioned PCMHs as “an approach to providing comprehensive primary care for children, youth and adults.”
The Agency for Healthcare Research and Quality (AHRQ) holds that there are five components of the PCMH: that it provides comprehensive care, it’s patient-centered, emphasis is placed on coordinated care, services are widely accessible, and it “demonstrates a commitment to quality and quality improvement.”
Taken together, these components create a tightly-coordinated care environment. To get a better feel for what the AHRQ sees as the ideal PCMH, let’s examine each facet separately.
Comprehensive Care: The care delivery model of a PCMH is comprehensive in that it must meet the majority of both a patient’s physical and mental health care needs. I’ve covered the importance of co-locating services like this in previous blog posts about mental health and PHM and place-based care in the UK. Services covered by a PCMH include “prevention and wellness, acute care, and chronic care,” and can include both in-person and virtual teams of physicians.
Patient-Centered: Medical teams comprising the PCMH model focus on the “whole person.” And what is whole-person health? According to the NIH, this idea involves examining “the connections between lifestyle, diet, genetics, health, and disease” to improve people’s health. It stands in stark contrast to the way medicine has traditionally been practiced, i.e. ignoring social and environmental context and looking only at separate bodily systems and organs to isolate problems and find remedies.
Approaching care in this way facilitates earlier, more effective interventions that can, in many cases, mitigate poor outcomes. To this end, says the NIH, “Understanding the condition in which a person has lived, addressing behaviors at an early stage, and managing stress can not only prevent multiple diseases but also help restore health and stop the progression to disease across a person’s lifespan.
Coordinated Care: AHRQ states that “the primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports.” But why is coordinating care important?
One study out of the University of Texas at Austin makes the case:
“A decade of research into organizations that have achieved better outcomes while often lowering costs suggests a strategic framework for value-based health care implementation that starts with identifying and understanding a segment of patients whose health and related circumstances create a consistent set of needs. An interdisciplinary team of caregivers then comes together to design and deliver comprehensive solutions to address those needs.”
And funding is increasingly tied to this kind of team-based care. Said another way, to achieve better outcomes, coordinated care is often one major goal of value-based care models. PCMHs excel in this area. Indeed, one study found that “PCMH performed significantly better in care coordination compared to non-PCMHs” in their use of case managers, the clinical quality of care reports, and their diligence in sending reminders for preventive or follow-up care. Adopting features of the PCMH model, say the authors, can improve care coordination, especially when it comes to preventive care services.
Wide Accessibility: One simple phrase that appeared in an American Journal of Medical Care article nicely sums up this concept: “Outcomes start with access.”
The authors go on to say that “Patients with limited access to care, whether the barriers are geographic, financial, or cultural and linguistic in nature, are more likely to delay necessary care and, down the road, be hospitalized for their condition.”
Access to care is a central tenet of population health management, and this includes providing diverse channels of communication (emails, phone calls, patient portals), ensuring shorter waiting times, and even extending working hours to accommodate patients with non-traditional job schedules.
I find this latter example – extending working hours – particularly compelling with respect to expanding accessibility. In keeping with this idea, this 2016 article now seems prescient given the enormous hurdles COVID has constructed over the past couple of years. Beyond providing multiple successful examples of physicians extending hours to accommodate their patients, the author also cites a UK study that found that “Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for ‘minor’ problems.”
Demonstrated Commitment to Quality and Safety: “In healthcare,” say the authors of a recent blog post about quality measure development, “what gets measured gets done.” This sentiment has never been more true than in the current era of alternative payment model adoption.
The Health Care Payment Learning & Action Network (HCP-LAN, or “LAN” for short) is my go-to place for keeping up with trends in quality measure adoption, and according to their latest data, “In 2020, 40.9% of U.S. health care payments, representing approximately 238.8 million Americans and 80.2% of the covered population, flowed through Categories 3 & 4 models.” According to the LAN, “Category 3” alternative payment models (APMs) are those built on fee-for-service architecture, whereas “Category 4” APMs are “Population-Based Payment Models” (read more about Population-Based Payment Models here).
More comprehensive information can be found here, but suffice it to say that these numbers, which track how much care is being delivered through APMs, are generally on an upward trajectory. That means that fee-for-service is slowly going away, with these value-based forms of physician reimbursement taking its place.
Given the evolving payment landscape, PCMHs are well-situated since the AHRQ points to “engaging in performance measurement and improvement” and “measuring and responding to patient experiences and patient satisfaction” as two hallmarks of the PCMH model. It remains to be seen if PCMHs will emerge from this transitional period intact, but from everything I’ve seen, I think they stand a good chance of going the distance.