Thursday, July 15, 2010

Patient-Centered Medical Homes Gain Ground - NYTimes.com

For several years now and with a growing messianic fervor, physicians and health care experts have been responding to the need to deliver more efficient and better primary care with one response: patient-centered medical homes.

Not long ago, I found myself doing the same with a friend who prides himself on being a well-informed patient. But instead of an overwhelmingly enthusiastic or even mildly interested response, my friend stared at me blankly.

"What in the world are you talking about?" he finally asked. "A hospice? A halfway house? Some kind of group home for patients?"

I explained that a patient-centered medical home can be any primary care doctor's office, but it is run with a different philosophy. Care is team-based, preventive and comprehensive, rather than one-on-one, fee-for-service or managed. Record keeping and sharing is seamless and electronic, rather than unwieldy and paper-based. Clinicians from the team are easily accessible in person, on the phone or via the Internet within 24 hours, rather than hidden behind labyrinthine automatic answering services and overbooked clinic schedules.

My friend suddenly became very interested.

Call it a P.R. issue, an information disconnect or simply an unfortunate choice of a name, but in all the discussions about patient-centered medical homes, one group of individuals has been conspicuously missing: the patients themselves. And it's hard not to notice the irony; in a model of care premised on the strength of the patient-doctor relationship, few people other than doctors and experts are even sure what it is or how it affects their care.

Now, as dozens of pilot projects across the country are transforming traditional doctors' offices into medical homes and putting this theory of practice to the test, one thing has become apparent: even this most promising of reforms is unlikely to take hold without the active involvement of patients.

The need to get patients involved was made startlingly clear last month when the American Academy of Family Physicians, a national medical society devoted to primary care, and TransforMED, a nonprofit consulting firm created by the society to help physicians turn their practices into medical homes, published the first report on their national demonstration project. Beginning in 2006, 36 traditional primary care offices began adopting the hallmarks of patient-centered medical home practices. They installed electronic medical record systems and reorganized deeply entrenched scheduling routines. Teams made up of nurses, medical managers, physician assistants and doctors, rather than a single physician authority figure, began working with patients. And care was focused not on single acute episodes of illness but on the patients' comprehensive and ongoing management.

As the study progressed, the researchers found that the vast majority of doctors' offices could successfully incorporate most of the changes into their practice, and early signs of the model's success were promising. Quality of care and preventive health ratings revealed small improvements. Office staff became more streamlined, efficient and satisfied. Most notably, physicians were more content than ever before with their work, despite still having to deal with an unchanged fee-for-service or managed care reimbursement system. The doctors' enthusiasm persisted even after the study closed, with many maintaining contact with one another through a listserv and twice-yearly self-organized meetings.

Yet despite these successes, there was also one unexpected early finding: the patients were unhappy.

Yes, they were getting into their doctors' offices more quickly and were being followed more closely than ever before, but many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them.

In working so hard to adopt changes on their patients' behalf, clinicians had temporarily lost their focus on the patients themselves.

"The Achilles heel of all of this is a lack of patient understanding and engagement," said Dr. Terry McGeeney, a primary care physician and chief executive of TransforMED. "Patient-centered medical homes are a massive paradigm shift in how primary care practices function." As one of the first national studies of patient-centered medical homes, "we were starting at ground zero, and we weren't aware of what we needed to do other than support the physicians' personal motivation."

With the patient survey results in hand, the researchers began encouraging medical practices to involve patients in the changes. They asked clinicians to discuss the premise of medical homes with their patients and encouraged them to create patient advisory councils, groups of patients who would meet regularly with clinicians to discuss how their needs might be better served.

"We were surprised by how many patients wanted to be part of it," said Dr. Barbara Saul, a primary care physician in Troy, Mich., who was initially part of the study. "Patients would say over and over, 'It's about time you started these kind of changes.' "

The researchers also created a five-minute, 20-question assessment survey that asks patients for their views on patient-provider communication, clinician access and care of the whole person. Practices could use the survey regularly to gauge the effects of any changes, adjusting and refining what they do according to the patients' experiences and not what the clinicians might believe was most important to them.

"Nowadays a lot of patients end up getting things done to them, almost forced on them," said Dr. Joseph Mambu, a practicing family physician in Lower Gwynedd, Pa., a suburb of Philadelphia. "I think if we could see a situation the way a patient does, a lot of the things we do would not be done." Based on his experience with the national demonstration project, Dr. Mambu went on to help create a national coalition of patient advocacy groups, payers and providers, the Patient-Centered Primary Care Collaborative, devoted to creating more medical homes across the country.

While Dr. McGeeney and his co-investigators believe that such work and ongoing research will yield even more significant results in terms of improving the quality and decreasing the costs of primary care, the lesson from this first experiment is clear.

"The model can improve quality while becoming more efficient, but practices need support," Dr. McGeeney observed. "Providers need to want to provide this kind of care, payers need to pay for this kind of care and, most importantly, patients need to demand and expect this kind of care."

http://www.nytimes.com/2010/07/15/health/15chen.html?hpw