A Guide to the Medical Home as a Practice-Level Intervention

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Supplements and Featured Publications, Best Practices and Innovative Healthcare Reform Models, Volume 15, Issue 10

The medical home (also known as patient-centered medical home or advanced medical home) is a composite policy construct representing a set of interventions intended to revitalize primary care practices and improve patient care. As an idealized vision, the medical home has gained the support of stakeholders including employers, health professional societies, health plans, not-for-profit entities, and government agencies. Expectations of the medical home include improvements in healthcare quality, patient experience, provider work-life satisfaction, costs of care, and increased recruitment of medical students into primary care careers. However, multiple definitions of the medical home exist, and the degree to which some often-cited examples of "medical home" successes match these definitions is unclear. Scant evidence currently supports the effectiveness of practice-level medical home interventions for improving quality and reducing costs, but demonstration projects are only recently under way. Carefully specifying the exact components of "medical home" interventions-and interpreting their results in the context of these specifications-will help build a coherent body of evidence to guide the revitalization of primary care.

(Am J Manag Care. 2009;15:S291-S299)

Overview

The medical home (also known as patient-centered medical home or advanced medical home) is a composite policy construct applied to interventions intended to revitalize primary care practices and improve patient care. It is hoped that these interventions will increase the appeal of primary care as a medical career and improve healthcare quality, patient experience, provider work-life satisfaction, and costs of care. This article is intended as a guide for policymakers, healthcare purchasers, and physicians who are thinking about facilitating, paying for, or engaging in medical home interventions.

The phrase "medical home" has multiple definitions, and each definition contains many components. There can be confusion over what is meant when somebody proposes participation in (or reports having engaged in) a medical home intervention. To facilitate comparisons between medical home definitions, we classify their components into resource inputs, specified processes, and desired outcomes. We then apply a parallel classification system to the descriptions of medical home interventions that have already reported results. This review summarizes the findings and discusses their implications for future work.

Definitions of the Medical Home

The term medical home originated in a 1967 proposal from the American Academy of Pediatrics (AAP) intended to establish centralized, accessible medical records for medically complex, chronically ill children.1 Since then, physician professional societies have expanded the definition of the medical home to include a broader array of practice capabilities and elements of the Chronic Care Model, culminating in the 2007 Joint Principles of the Patient-Centered Medical Home issued by the American Academy of Family Physicians (AAFP), AAP, American College of Physicians, and American Osteopathic Association.2,3 As an idealized vision of primary care, the medical home is supported by stakeholders including employers, health professional societies, health plans, not-for-profit entities, and government agencies.4

Despite wide acceptance, the Joint Principles have not easily translated into concrete actions. Some principles describe processes to be undertaken by physician practices, but others describe new goals for a patient's total healthcare experience (ie, goals compatible with an idealized vision of primary care). The Joint Principles do not provide a complete action path for primary care practices seeking to reach these idealized goals. Instead, many practices and demonstration projects rely on an operational definition developed by the National Committee for Quality Assurance (NCQA): the Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH).5 The NCQA provides certification that individual primary care practices possess specific structural capabilities and partake in certain processes, and offers 3 levels of medical home recognition. In some medical home demonstrations, this certification process is used to determine whether participating practices qualify for enhanced payments. A variant of this NCQA definition was devised for use in the planned Medicare medical home demonstration authorized by the Tax Relief and Health Care Act of 2006.6,7

Another operational definition was developed by TransforMed, an AAFP subsidiary originally intended to facilitate the practice transformations envisioned in the AAFP's 2004 report "The Future of Family Medicine."8 With the advent of the medical home, TransforMed's mission evolved to include a prominent National Demonstration Project that uses its own medical home definition.9

Similar to the NCQA definitions, TransforMed's definition applies to individual primary care practices.

Components of the Medical Home

Each medical home definition comprises a set of specific components for primary care practices. The elements of these definitions fall into 3 fundamental categories: desired outcomes (ie, characteristics of care received by patients), specified processes for primary care practices to follow, and resource inputs to support these processes.

Table 1

Desired outcomes. Desired outcomes expressed in the Joint Principles include first contact, continuous, comprehensive care; care that is coordinated across the healthcare system and community; culturally and linguistically appropriate care; safe, high-quality, evidence-based care; and enhanced access (). Although not mentioned in the Joint Principles, medical homes are expected to reduce costs of care, improve provider worklife satisfaction, and draw more medical students into primary care.10 Better cost control can result from processes such as enhanced access (eg, so that patients can substitute away from high-cost care in emergency departments) and care management.11,12 Increased payments to medical homes may result in higher take-home incomes for primary care physicians, or not.13 Higher incomes, coupled with improved professional satisfaction, may increase the number of medical students choosing primary care careers.14

Specified processes. The processes of care specified in the major medical home definitions can be classified into categories corresponding to the desired outcomes expressed in the Joint Principles (Table 1). The Joint Principles do not specify which processes would enable practices to achieve first contact, continuous, and comprehensive care. To produce these outcomes, the PPC-PCMH and TransforMed definitions have focused on improving continuity through new appointment scheduling procedures. Recognizing the importance of mutually understood responsibility, the Medicare demonstration would require written agreements between patients and medical homes that delineate the expectations of each party.7

Coordinated care can be achieved through processes such as care management by nonphysician staff and the use of information technology. A variety of specified processes are intended to achieve safe, high-quality care: advanced electronic health records, test tracking, and targeted quality improvement activities. The processes intended to achieve enhanced access include "open scheduling" (to allow same-day appointments), expanded office hours, and enhanced telephone and electronic communications.

Some specified processes are not clearly tied to any particular desired outcome. The Joint Principles call for the use of a physician-led care team, and other definitions encourage structured templates for office notes and written policies for practice governance.5

Table 2

Resource inputs. To support investment in medical home processes, payers and demonstration collaboratives provide resource inputs to participating practices. These resources take the form of additional payment (included in both the Joint Principles and planned Medicare demonstration), in-kind investments (not included in any major definition), and technical support for practice transformation (included in the Medicare and TransforMed definitions) (). Of note, the PPC-PCMH definition-primarily intended as a practice certification tool-does not specify any resource inputs to primary care practices. These inputs are left to the payers and demonstration collaboratives that will facilitate each medical home intervention.

Will Medical Home Interventions Produce the Desired Outcomes?

Each medical home intervention consists of a combination of resource inputs and specified processes applied in a particular practice setting. Numerous studies of individual inputs and processes of the medical home have been published, and many of these individual components-especially those included in the Chronic Care Model-have been associated with favorable effects on clinical outcomes, clinical processes, and quality of life.15,16 The use of health information technology, studied primarily in a few large academic institutions, was also associated with favorable effects on quality of care.17 These studies of individual inputs and processes have helped guide the creation of medical home definitions, but they may not accurately predict the effects of more complex medical home interventions.

From the perspective of stakeholders considering a medical home intervention, the best guidance is likely to come from published evaluations of practice transformations that include multiple medical home components. These evaluations measure the overall effects of medical home interventions, net of any synergistic or antagonistic interactions among their components. In reviewing the results of published medical home evaluations, there are 3 main questions to ask. First, what were the intervention components (ie, what were the resource inputs and specified processes, and how completely did the intervention components match the major medical home definitions)? Second, what outcomes did the intervention produce? Third, what is the strength of the evidence, and how well do the findings generalize?

Components of Reported Medical Home Interventions: Settings, Inputs, and Processes

Table 3

A small number of medical home interventions have already reported results: the Group Health Cooperative (GHC), TransforMed, Geisinger Health System's Proven-Health Navigator, Intermountain Healthcare Care Management Plus, Geriatric Care Resources for the Assessment and Care of Elders (GRACE), and Community Care of North Carolina (CCNC) ().18-20 These interventions began before the March 2007 publication of the Joint Principles of the Patient-Centered Medical Home as well as the major operational definitions of the medical home. In a sense, these interventions have been rebranded as medical home interventions, and vary in the extent to which they match the major medical home definitions.

Practice settings. Among these 6 interventions, 3 (GHC, Geisinger, and Intermountain) occurred in practices that were part of large, integrated delivery systems (Table 3).21-23 The GRACE and CCNC interventions both involved levels of provider organization beyond the primary care practice.24,25 Only TransforMed's intervention took place within independent primary care practices.9

Resource inputs. Three of the interventions (GHC, Geisinger, and CCNC) provided additional payment to participating practices, with Geisinger being the most generous.22 Two of the interventions provided technical support to participating practices (TransforMed and CCNC). Excepting TransforMed, all interventions provided in-kind investments, most commonly in the form of additional staff to perform case management.

Specified processes. The 6 medical home interventions have also varied in the extent to which their specified processes have matched the medical home definitions. By default, the processes of the TransforMed intervention constitute a perfect match to a major medical home definition. However, TransforMed's preliminary qualitative findings suggest that performing the specified processes (eg, adopting electronic health records) has been difficult, and practices have exhibited change fatigue.26 The number of practices able to successfully perform TransforMed's processes has not yet been published.

The GHC and Geisinger interventions each included multiple processes of the medical home, particularly those related to care management, patient self-management support, and use of electronic health records. As with TransforMed, GHC practices reported difficulties in changing the work processes of professional staff.27 The Intermountain, GRACE, and CCNC interventions, however, involved fewer specified processes of the major medical home definitions. The Intermountain and GRACE interventions included care management processes that were provided by the same care managers who constituted the practice inputs. Each Medicaid enrollee in CCNC was required to designate one practice as a "medical home." However, most processes of the CCNC intervention were performed by network staff; CCNC has not expected redesign of its participating practices.25

Have the Desired Outcomes Been Achieved in Demonstration Projects?

Table 4

The GHC's intervention is the only "medical home" intervention that includes a wide variety of medical home components and has produced a peer-reviewed evaluation. At 12 months, the GHC intervention reported improvements in multiple domains of patient experience (including coordination of care and access) and a global composite measure of technical quality of care ().21 There was no detectable effect on overall healthcare costs. However, with only one intervention practice and an integrated insurer/multispecialty group (with salaried physicians at baseline) as the intervention setting, the generalizability of these findings to independent primary care practices may be limited.

As noted earlier, TransforMed released preliminary qualitative results,26 but full evaluation results have yet to be published. Preliminary results from the first 2 pilot practices in Geisinger's medical home intervention included a 20% drop in hospital admissions, improvements in guideline adherence, and a 7% reduction in overall costs of care.22,28 The Geisinger medical home intervention was subsequently extended to another 21 Geisinger-owned practices and 4 independent practices, and preliminary results from a subset of these expansion practices include a 4% reduction in costs of care.28 The methodology underlying these cost estimates has not been completely described, nor have these estimates been presented in a peer-reviewed scientific publication. As with the GHC evaluation, the generalizability of Geisinger's findings to independent primary care practices may be limited.

Compared with matched controls, medically complex patients in Intermountain Healthcare's Care Management Plus intervention practices exhibited a trend toward lower 2-year all-cause mortality (16.6% among controls vs 13.1% in the intervention, P = .07).23

Compared with patients receiving usual care, elderly indigent patients receiving the GRACE intervention reported higher health-related quality of life and had lower 2-year rates of emergency department use (1748 vs 1445 visits per 1000 patients;

P = .03).29 CCNC's outcomes have included hundreds of millions of dollars in estimated annual savings to North Carolina's Medicaid program.30 Neither the Intermountain, GRACE, nor CCNC interventions closely matched the medical home definitions, so their generalization to proposed medical home interventions bears scrutiny. In addition, the methodology used to estimate the savings attributed to CCNC has not been completely described in publicly available materials, and these estimates, which have some skepticism,31 have not been presented in a peer-reviewed scientific publication.

Summary State of the Evidence

Currently, there is limited evidence that the medical home, as a multifaceted practice-level intervention, will produce the results expected by its stakeholders. Comparing Table 1 to 3 demonstrates that some interventions cited in support of the medical home bear little resemblance to the major practice-level medical home definitions-particularly in the degree of practice transformation required. Other interventions occurred in unusual organizational settings, and some prominent results have not been peer-reviewed.

To take advantage of current political opportunities, policy-level decisions about transforming primary care practices will be running ahead of the evidence. However, medical home pilot projects in several states are under way, and many others are planned.7,32

Although their diversity may frustrate efforts to pool results, these pilots offer a chance to carefully examine which combinations of medical home settings, inputs, and processes are likely to produce the best results.

Guidance for Stakeholders

Beyond the need to test the medical home, there is a need to clearly specify what is being tested: for each intervention, exactly what are the practice settings, practice inputs, and specified processes?33 Without careful identification of medical home components, the use of the phrase "medical home" risks transmitting the appearance of failure (or success) across interventions that have little else in common. For example, practice transformation that is facilitated by significant practice inputs and in-kind support from an integrated health system may lead to desirable outcomes. However, these outcomes may not accurately predict the results of interventions on independent primary care practices (or interventions lacking significant practice resource inputs). Stakeholders who expect a proposed medical home intervention to produce GHC- or Geisinger-like results should ask: to what extent are the setting, practice inputs, and specified processes of the proposed intervention congruent to these prior examples?

Because of its common use in medical home pilots, it is worth pointing out that the NCQA's PPC-PCMH, as a certification instrument silent on practice inputs, cannot completely define a medical home intervention. In addition, the PPC-PCMH does not completely specify the combination of processes expected of primary care practices. Each level of NCQA medical home certification can be achieved in many different ways. If medical home pilots require NCQA certification but give no further guidance about which particular PPC-PCMH elements are expected, the resulting intervention may need to be analyzed as a heterogeneous family of experiments.

The Medical Home in the Context of Overall Primary Care Reform

Well-respected observational research supports the superiority of a primary care-oriented healthcare delivery system.34,35 Based on existing evidence, it is unclear whether the transformation of individual primary care practices is the best path to this goal. Other avenues can simultaneously be explored. For example, the recently announced Medicare-Medicaid Advanced Primary Care Demonstration Initiative will evaluate interventions including the majority of primary care practices in each participating state.36 The proposed expansion of the Medicare Physician Group Practice Demonstration may create accountable care organizations that integrate individual primary care practices into full-service health systems.37 Accountable care organizations may enhance the ability of primary care practices to perform core medical home processes and to share in savings generated across all care settings.38 Results from these new efforts and ongoing medical home demonstrations will provide valuable guidance to the overall revitalization of primary care.

Author Affiliations: From RAND, Arlington, VA (MWF, PSH), Santa Monica, CA (DJL), Boston, MA (ECS).

Funding Source: Financial support for this work was provided by GlaxoSmithKline.

Author Disclosure: The authors (MWF, DJL, PSH, ECS) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MWF, PSH, ECS); acquisition of data (MWF, DJL); analysis and interpretation of data (MWF, DJL, PSH, ECS); drafting of the manuscript (MWF, DJL, ECS); and critical revision of the manuscript for important intellectual content (MWF, PSH, ECS).

Address correspondence to: Mark W. Friedberg, MD, MPP, Associate Natural Scientist, RAND, 1776 Main St, PO Box 2138, Santa Monica, CA 90407-2138. E-mail: mfriedbe@rand.org.

1. Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics. 2004;113(5 suppl):1473-1478.

2. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74(4):511-544.

3. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. 2007. www.medicalhomeinfo.org/Joint%20Statement.pdf. Accessed November 3, 2009.

4. Patient-Centered Primary Care Collaborative. Patient-centered medical home. http://pcpcc.net/content/patient-centered-medicalhome. Accessed November 3, 2009.

5. National Committee for Quality Assurance. Standards and guidelines for physician practice connections-patient-centered medical home (PPC-PCMH). Washington, DC; 2008.

6. National Committee for Quality Assurance. Standards and guidelines for physician practice connections-patient-centered medical home (PPC-PCMH) CMS version. Washington, DC; 2008.

7. Mathematica Policy Research Inc. Design of the CMS medical home demonstration. Princeton, NJ: Mathematica; 2008.

8. Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2(suppl 1):S3-S32.

9. TransforMed. National Demonstration Project. http://www.transformed.com/ndp.cfm. Accessed November 3, 2009.

10. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;359(12):1202-1205.

11. Mehrotra A, Liu H, Adams JL, et al. Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Ann Intern Med. 2009;151(5):321-328.

12. Bodenheimer T, Berry-Millett R. Follow the money-controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521-1523.

13. Zuckerman S, Merrell K, Berenson R, et al. Incremental cost estimates for the patient-centered medical home. New York: The Commonwealth Fund; October 2009.

14. Phillips RL, Dodoo MS, Petterson S, et al. Specialty choice and geographic distribution of the physician workforce: what influences medical student and resident choices? Washington, DC: The Robert Graham Center; March 2, 2009.

15. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11(8):478-488.

16. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1):75-85.

17. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742-752.

18. Grumbach K, Bodenheimer T, Grundy P. The outcomes of implementing patient-centered medical home interventions: a review of the evidence on quality, access and costs from recent prospective evaluation studies. University of California, San Francisco Center for Primary Care Excellence; August 2009.

19. Patient-Centered Primary Care Collaborative. Evidence of the effectiveness of the patient-centered medical home on quality and cost. http://pcpcc.net/content/evidence-quality. Accessed November 3, 2009.

20. Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008;21(5):427-440.

21. Reid RJ, Fishman PA, Yu O, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009;15(9):e71-e87.

22. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27(5):1235-1245.

23. Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008;56(12):2195-2202.

24. Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136-1141.

25. Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA Jr. Community Care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6(4):361-367.

26. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254-260.

27. McCarthy D, Mueller K, Tillmann I. Group Health Cooperative: reinventing primary care by connecting patients with a medical home. New York: The Commonwealth Fund; July 2009.

28. McCarthy D, Mueller K, Wrenn J. Geisinger Health System: achieving the potential of system integration through innovation, leadership, measurement, and incentives. New York: The Commonwealth Fund; 2009.

29. Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-2633.

30. Community Care of North Carolina. External Evaluations. http:// www.communitycarenc.com/. Accessed October 25, 2009.

31. Brown R. Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities. Princeton, NJ: Mathematica Policy Research; September 2009.

32. American College of Physicians. Patient-centered medical home: state-by-state demonstration list. 2009. http://www.acponline.org/running_practice/pcmh/demonstrations/locations.htm. Accessed November 3, 2009.

33. Barr MS. The need to test the patient-centered medical home. JAMA. 2008;300(7):834-835.

34. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

35. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality of care. Health Aff (Millwood). 2004;Suppl Web Exclusives:W184-W197.

36. Healthreform.gov. Medicare-Medicaid Advanced Primary Care Demonstration Initiative. 2009. http://healthreform.gov/newsroom/factsheet/medicalhomes.html. Accessed November 3, 2009.

37. Crosson FJ. 21st-century health care-the case for integrated delivery systems. N Engl J Med. 2009;361(14):1324-1325.

38. Rittenhouse DR, Shortell SM, Fisher ES. Primary care and accountable care-two essential elements of delivery-system reform. N Engl J Med. 2009;29:29.