Those of you who follow me on twitter may know that I traveled to Washington DC late last week to take part in a “roundtable event” discussing paths to better diabetes care. Now, I’m no policy-maker, and certainly no expert on the crazy mixed-up reimbursement system in this country. I was there, again, to talk about what’s wrong with the way most diabetes patients are treated now, and what’s needed to make it better.
Once again, my bit was a call for better coordination of care (“healthcare team,” my ear!) and providing patients the education and ongoing coaching they so desperately need. We talked a lot about how all the new web-based health tools (Health 2.0 stuff) might be employed by patients and their doctors together to actually help patients do better in real life (remember that, Doc?)
Image: Texas Family Physician
The most eye-opening thing to me about this meeting was learning about the so-called “Patient Centered Medical Home.”
I’d heard the term many times before, and admittedly, paid little attention because I assumed it had to do with home-based healthcare for the elderly. Actually, it’s a movement – a sweeping initiative to improve medical care in this country by creating all-inclusive clinics where primary care docs not only offer preventive health counseling, screenings and immunizations, but also provide “care advocacy” with patients and family members, and coordinate care with on-site specialists – all at incredibly reasonable prices. These wonder-clinics would become the patient’s “medical home.”
Check out this list of guiding principles:
• Personal physician: “each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.”
• Physician directed medical practice: “the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.”
• Whole person orientation: “the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.”
• Care is coordinated and/or integrated, for example across specialists, hospitals, home health agencies, and nursing homes.
• Quality and safety are assured by a care planning process, evidence-based medicine, clinical decision-support tools, performance measurement, active participation of patients in decision-making, information technology, a voluntary recognition process, quality improvement activities, and other measures.
• Enhanced access to care is available (e.g., via “open scheduling, expanded hours and new options for communication”).
• Payment must “appropriately recognize[s] the added value provided to patients who have a patient-centered medical home.” For instance, payment should reflect the value of “work that falls outside of the face-to-face visit,” should “support adoption and use of health information technology for quality improvement,” and should “recognize case mix differences in the patient population being treated within the practice.”
Sound too good to be true? Sure does to me. But it’s actually happening at dozens of pilot sites around the country, according to the Patient-Centered Primary Care Collaborative, a huge national collaborative whose executive director took part in the roundtable event.
The PCPCC was founded by IBM in 2005, and is backed by some 500 large employers, insurers, consumer groups, and doctors, including the American College of Physicians and the Academy of Family Physicians (who knew?)
Sounds like we all should be enjoying this “new model of care” by now, but we’re not. In fact, I never met a single person who is… I guess you have to be lucky enough to be in the right place with the right employer (story of our lives, ay?)
I should note that the PCPCC website itself contains a lot of good information. You can watch a video about patient-centered healthcare, or download a consumer guide to e-prescribing.
Surveying the blogosphere, I noticed there’s some institutional discord about how to evaluate the Medical Home sites that are up and running, i.e. the authorities seem to be using old data-based methods for reviews, rather than asking patients directly about their experiences (not a good sign).
So here is my question: Do any of you PWDs out there have experience in a Patient-Centered Medical Home environment?
Is it really as amazing as it sounds? Or is this mainly a lot of lip-service over some slightly-more-coordinated clinics than we’re used to?
While not a diabetic, I’ve been involved in health care as a physician in practice for over 27 years, and in working in a health care collaborative (Institute for Clinical Systems Improvement–icsi.org) for 8 years.
The impetus of the PCMH (or health care home as it’s called in Minnesota) has been growing. Indeed the principles espoused are laudable, and one can hardly disagree with any of them. As a previous primary care provider, they resonate.
The issue is demonstrated by several of your comments. First, when one hears the term “medical home” it often raises the image of a place, and not necessarily a good place–nursing home, funeral home–you get the drift. Secondly, while it sounds good, you yourself state you’ve not seen one, and certainly not experienced one. While there are multiple individual small projects in place, the challenges we face in moving toward the principles you noted are huge. How will this be paid for? Will physicians and other providers be willing to change their behaviors, be part of a “team” which includes the patients? Will we be able to communicate and coordinate in a way not even close to reality today?
But perhaps most important, at least as I see it, will diabetics (and other patients) be interested and willing to “move into” the PCMH we’re building. The need to take a more active role, the increased self management, the medical community’s expectation that all patients will successfully become “compliant” and adhere to the prescribed program is one which I as an educated, committed physician often times feel challenged to commit to. If I personally can’t do that, is it realistic to expect many of our patients to make the often drastic lifestyle changes we’d expect to successfully advance this. Much more to discuss, many more questions and uncertainties to consider, and a long journey we need to take together.
Thanks for your thoughtful and to me eye opening perspective on this concept.
I believe it is entirely possible, now that one missing component has come to be: Social Media
A few weeks ago I wrote a blog entry at http://www.tudiabetes.org/profiles/blogs/social-media-and-pharma-now that ties right into this
“More and more people are starting to realize that the docs are advisers only. The patient is beginning to understand that they are responsible for their health and your doctor should provide guidance for you to make the best decision about your health. This is also made possible by all the knowledge that is available via Social Media. It allows the patient to take that step to be the leader of a medical team that works for the patient to ensure their health. Before that knowledge, patients would tend to defer to whatever their doctor said because they didn’t have the knowledge to ask the questions. In general, I think that most doctors welcome this. It makes their job easier and a lot more effective.”
I’m glad to see the medical community starting to move in this direction. This is definately Health 2.0, in my humble, yet always correct opinion. /wink
Oh, and one other comment, you wrote:
“The need to take a more active role, the increased self management, the medical community’s expectation that all patients will successfully become “compliant” and adhere to the prescribed program is one which I as an educated, committed physician often times feel challenged to commit to.”
Compliance is currently defined as following the treatment regiment AND getting the expected results.
In diseases like diabetes, managing the condition on an all day/every day basis is much more an art-form than a science. Patients may not get the results desired while “complying” and often may hear that they need to “try harder”.
Compliance needs to be a two way street where patients comply with the regimen and doctor’s comply with patient’s goals. I.E. Think it may be just as likely that the regimen needs modification as it is that the patient is not working at it.
THANK you Scott for your very astute and clearly articulated comments in response to Gary O’s comments regarding “compliance” – a word I hate more than dirt! Too often doctors tell a patient what to do and get mad at the patient when they question the prescribed medication or plan or whatever, or worse – the prescription fails and the doctors let themselves off the hook by blaming the patient. This doesn’t work with a diabetic committed to handling this tricky disease 24/7. The point you make about a regimen needing modification is one ALL doctors should focus on – instead of always blaming the “non-compliant” patient. I have a real issue with this since the only reason I’m alive today is because I’ve known enough to know when not to listen to the advice of some doctor who had little real idea of how to treat me with T1D. The two-way street concept is one of the bigger hurdles we face and doctor’s need / must become more humane and compliant themselves with the notion that patients with D are multi-faceted complicated systems with very few simple solutions. Doctor’s want us to become more responsible for our own health, but at the same time they often resent it when we question their advice. WE all have to work together and each of us must take responsibility – we patients for our day-to-day and the doctor’s must take responsibility for knowing when they’re out to their league. So the concept of the health home is great, if the doctor’s really can work together in an integrated fashion and that in turn will encourage patients to take better care of themselves.
I agree with Scott. Interesting topic. Thanks for sharing.
I introduced the term “compliance” because for years I have been promoting it as one word I’d like removed from the medical vocabulary. More specifically, the term “non-compliant” is all too often used when patients seem to fail to follow what we in health care recommended or “ordered” (another word which needs to be reevaluate).
More recently, in what may be an effort to soften the impact of the compliance term, we’ve heard about “adherence” as a way of engaging patients.
In my mind, and perhaps only in mine, that still smacks of a paternalistic type of approach which seems to believe that external motivation will be successful in getting our patients to actively self manage their health issues, whether it be diabetes, heart disease, depression, etc. As we learn more about human behavior, an area which much of traditional medicine would benefit from studying, it is apparent why many of our efforts at engaging patients fail.
It is difficult enough to travel through life unencumbered by a chronic condition and maintain a healthy lifestyle. I know, because that could describe me. Add on one or more chronic conditions, and the increased need for focus, attention, will power, avoidance of self indulgence, becomes a constant drain on a finite energy source within any of us.
And then when we drift from the prescribed program, we are non compliant, often feel guilty, feel we’ve failed, and that begins a progressive downhill slide in our sense of self worth, ability to persevere, and may lead us to avoid talking with our health care providers–fearing the disappointed or often frustrated looks and words we may hear.
Perhaps I’m wrong, but I’ve read more and more on human behavior and much of what I read causes an almost tectonic shift from what I was taught decades ago in medical school. I’d recommend two recent books as being capable of causing great reflection and reevaluation–Drive by Daniel Pink, and Switch by Dan Heath. There are many others which I could draw from, but if you’re either working with patients with chronic conditions, or are a patient with a chronic condition, these may provide some moments of epiphany. Or perhaps they’ll reinforce the life you’re already struggling, dealing, and succeeding with. Thougts???
Gary,
That is exactly on point! And do I agree about the word adherence, “a rose by any other name…”
I really believe that the non-physical aspects are just as important as the physical ones when managing a chronic condition, sometimes even more so. I hope it will continue to become a larger part of managing chronic conditions.
What I am about to say may spawn some well deserved angry comments, so I’ll apologize now. I’ve had people (even nurses) say to me “Well, at least it’s not cancer.” I am always so tempted to reply that “No it isn’t. But at least with cancer you will either win or you will loose. With diabetes, there is no finish line. I will never win. The best I can hope for is a draw.” That is the biggest thing, in my opinion, that people (medical professionals included) just don’t seem to get. And that is probably because when I leave their office, they are able to move on to the next patient, whereas I have to walk-the-walk all day every day.
I was wondering how closely this resembles systems in other countries that have “house doctors”. I live in Hungary and we each have a house doctor who keeps track of all medical conditions, but it is more in the sense that I need a referral from her to go anywhere. She does not try to give advice on my type 1 diabetes (she knows that I know more than her about that and that I need a specialist). But that is where my “standard” blood work takes place and she writes all my prescriptions. Her office is on my block and I can go anytime (without an appointment), but usually need to wait up to an hour if it is crowded. She also makes house calls if I can’t make it around the corner to the office
I guess there is no real “wholistic” side to this system, but it is certainly different than the primary care physician in the USA.
In June 2010 FierceHealthCare reported: “The first national medical home demonstration has come to a close, and the 36 practices who put two years into transforming toward the model deliver somewhat discouraging news. Despite their intense efforts to implement same-day appointments, optimized office design, electronic prescribing, electronic health records, practice websites and more, the participating family practices registered modest improvements in quality-of-care measures but backslid in terms of how patients rated them, according to a set of eight articles in a special supplement of the Annals of Family Medicine.”
Other studies are reporting more positive results.
Regardless the concept of “patient-centeredness” is absolutely moving us in the right direction but many of the tactics are flawed. Some examples:
1.) Funding – Many of the PCMH pilots are using traditional Fee-For-Service plus Care Management Fees plus Pay-for-Performance “bonuses”. These funding strategies have been tried before and have not led to significant improvements in patient / family / community health. The driver of care remains productivity (increase number of patient visits and ancillary testing). [See book "Overtreated" by Shannon Brownlee.]
2.) Integration? – Many of the PCMH pilots are defining integration as a care team of Physician plus an extender plus a nurse/medical assistant plus perhaps a liaison. True Integration integrates physical, mental, emotional, spiritual aspects of healing and addresses barriers such as environmental, financial, nutritional, etc. The extender model has historically been leveraged to decrease medical practice overhead while providing access. It is not true integration but a means to a financial end (with the upside of improved access).
3.) Care Teams/Model – We have seen first hand that patients ideally want a “personal physician” not a doctor plus extender; Someone they know, trust, respect and someone who knows them. Someone who has the time to understand the root cause of an illness and will co-create a patient-specific treatment plan with the patient addressing the barriers to the individual’s health goals. Someone who can integrate a ideal team of healers specific to the needs of the patient, i.e., perhaps a physician trained in cutting-edge chronic disease management plus a psychiatrist to address with the patient mental health aspects of a disease and perhaps a nutritionist who is trained to work with the specific needs of the patient. A team of healers integrating and customizing their approaches to best meet the needs of a specific patient. With same patients are engaged, feel respected and heard, and are more compliant.
4.) Broken paradigm – The health care system remains broken. Productivity remains the driver behind financial stability of health care organizations. Physician specialties remain siloed. The Institute of Medicine has stated the approximately half of medicine lacks scientific validity. The current PCMH pilots are being built in this broken system.
So again, wonderful concept that may provide some improvements in some areas. But also great opportunities for improvement that can bring the system even closer to the ideal.
It is not true integration but a means to a financial end (with the upside of improved access).