Home sweet “medical home”

When I first read about the concept of the “patient-centered medical home” (PCMH) many years ago, and was managing a small but busy pediatric practice, I was puzzled by the fact that we had to question whether our practice was a “medical home.” I assumed that the comprehensive care we provided our patients was similar to the care provided by large group practices, hospital-run pediatric practices, or even public health clinics.

My practice was very patient friendly. We had convenient hours, offered same-day appointments, assisted patients with insurance issues and referrals, returned calls promptly, and helped parents navigate what at the time seemed to be a complicated health care system. Providers and staff were highly efficient at their jobs and kept things simple and straightforward. We were successful because we treated our patients and their parents as we would want to be treated ourselves. This concept, which I call the “Golden Rule of Pediatric Care,” has served me well for over 3 decades.

I now understand that the quality of care provided by a well-run, small private practice is frequently the exception rather than the rule. The larger the pediatric practice and the more diverse the patient base, the harder it is to provide a quality medical home for patients. In many large practices and some hospital-based clinics, patients consistently have difficulty seeing their primary care physicians (PCPs), and when practices try to achieve efficiency and conserve funds by “doing more with less,” the medical home concept breaks down quickly. Inefficient practices violate the golden rule when worried parents need to navigate a complex phone tree just to converse with a “person” who can help them with their problem, when calls don’t get returned promptly or are forgotten, and when routine health forms take an inordinately long time to complete. Practices that have not implemented the many V2.0 efficiencies we’ve described in this series just cannot function as a top-notch medical home.

Because of the acknowledged difficulties in providing patients with an efficient and caring medical home, V2.0 practices are encouraged to go through a voluntary and rigorous credentialing process to be officially recognized as a PCMH. By becoming accredited, practices can distinguish themselves from others, and they may have an advantage in an increasingly competitive marketplace. This article will present a brief overview of the current concept of a PCMH and describe how your practice can be officially credentialed.

Origin of the PCMH

The concept of the PCMH was introduced by the American Academy of Pediatrics (AAP) in a book, published in 1967, called Standards of Child Health Care, from the AAP Council on Pediatric Practice.¹ The medical home concept originally referred to 1 central source of medical records for children with special health care needs. Over the next 2 decades, the idea of the medical home changed from that of a data repository to that of how best to deliver care for children. In 1992, the AAP issued a revised policy statement that described the functions of a pediatric practice medical home.² According to the statement, a medical home provides:

• Preventive care services including immunizations, developmental checks, and health care screening and supervision;

• Assured access to acute care services 24/7;

• Continuity of care over an extended period of time;

• Facilitated access to specialists;

• Interaction with schools and community agencies to provide coordination of care; and

• A location for storage and access to a patient’s complete medical record.

Furthermore, the 1992 policy statement noted that these characteristics have traditionally been provided by pediatricians to their patients, contrasting with those provided by emergency departments (EDs) and walk-in clinics.

The policy was revised again in 2002.³ Calvin Sia, MD, FAAP, who pioneered the implementation of the medical home concept in Hawaii in the 1970s and 1980s, chaired the Medical Home Initiatives for Children With Special Needs Project Advisory Committee that authored the revised AAP medical home policy in 2002. Regarding the evolution of the medical home concept, he said: “Nationally, the medical home concept began to evolve from a centralized medical record to a method of providing primary care from a community level, recognizing the importance of addressing the needs of the total child and family in relationship to health, education, family support, and the social environment. The concept assumed a bottom-up, or grassroots, approach rather than a top-down approach and shifted toward prevention, wellness, and early intervention.”⁴

The 2002 AAP policy statement listed in great detail how practices provide the services that should be provided by a medical home.³ To improve access to care, the AAP policy recommended that practices accept all insurances including Medicaid, and be conveniently located to be accessible by public transportation. To provide family-centered care, pediatricians, patients, and families should share responsibility in decision making. To improve continuous, comprehensive, and coordinated care, a patient should have a PCP who would be responsible for the child’s health needs 24/7, from childhood through adolescence. The PCP coordinates care with community agencies and hospitals; provides immunizations, developmental assessments, and screening tests; and facilitates access to specialists when indicated. Lastly, the policy stated that any care provided by pediatricians should be compassionate and culturally effective.

It has long been the goal of the AAP that all patients, independent of insurance status, have a PCP and a PCMH. With ready access to a medical home, patients receive proactive rather than reactive medical care, and hospitalization and ED utilization rates would decline significantly.

In 2007, a joint statement issued by the AAP, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association endorsed the PCMH concept and described how the PCMH can optimize care for patients.⁵ In addition to identifying the PCP as the leader of a team whose role is to provide and coordinate patient care, the joint statement further elaborated upon the previous AAP policy by emphasizing that physicians should adhere to evidence-based guidelines, advance the use of information technologies to improve care, and implement practices that improve the quality of care provided to patients. It said that practices should be compensated for services and time spent in coordinating care for patients, not just for the face-to-face time with physicians. The statement also encouraged practices to become officially credentialed as a medical home, and noted that practices should receive additional payments for proving that they are achieving “measurable and continuous” improvement in the quality of care provided to patients.

Getting accredited

Several organizations provide official accreditation for PCMH designation. These are the National Committee for Quality Assurance (NCQA), URAC (formerly the Utilization Review Accreditation Commission), the Joint Commission, and the Accreditation Association for Ambulatory Health Care (AAAHC). The NCQA has the oldest and most well-known program, and, according to information posted on its website, the organization has so far recognized nearly 30,000 physicians and more than 6,000 practice sites nationwide.⁵ Keep in mind that there are more than 330,000 PCPs in the United States,⁶ so only a small percentage of physicians have been credentialed so far.

The Joint Commission, URAC, and the AAAHC use an on-site survey to credential practices, while NCQA credentials practices by reviewing a survey tool that requires practices to provide extensive documentation that they meet PCMH criteria. The NCQA survey tool involves a review of 6 standards that must be met in order to pass. These include assessments of a practice’s ability to provide continuity of care; manage patient populations; plan and manage care; facilitate access to community resources; track and coordinate care; and measure and improve performance (Table).⁷

The NCQA has 3 levels of recognition. Although a practice can earn Level 1 or Level 2 PCMH recognition without an electronic health record (EHR), Level 2 recognition is easier to achieve with a basic EHR. In order to earn the necessary points for Level 3 recognition and to generate the documentation that meets the requirements for that level,, a practice must use a “fully functional” EHR. Additionally, in order to meet all the must-pass elements for any level of recognition, a practice must use a practice management system.

The NCQA charges practices $80 for a survey tool license and $500 per physician up to 7 providers, and maxes out at $7,000 for large practices. The URAC’s fees include both an on-site survey fee of $1,500 to $4,500 and an administration fee of $720 to $2,400. The Joint Commission is the most expensive, with fees that can total up to $27,000 billed over a 3-year period. The AAAHC is the least expensive with an on-site survey fee of just $3,500. Certification is good for a period of 3 years and then the practice would need to undergo another review to demonstrate continuing compliance with PCMH requirements.⁸

Roadblocks to PCMH status

Obtaining PCMH credentialing is both time intensive and expensive. Implementation of an enterprise-level EHR is necessary to satisfy the many rigorous criteria associated with full certification. A recent survey of pediatric practices showed that only 25% of pediatric practices were using a basic EHR, while 6% were using a fully functional EHR.⁹ A review of a representative sample of pediatric practices nationwide showed that, on average, pediatric practices achieve only 38% of medical home infrastructure points, and most would not qualify for NCQA Level 3 certification.¹⁰ In this study, most pediatric practices met standards for enhanced access and continuity, and for providing self-care support and community resources. However, fewer than half of primary care practices met standards for planning and managing care, tracking and coordinating care, and measuring and improving performance. Low scores were a result of few practices reporting computerized systems that facilitated patient-management tasks.

Revisiting the golden rule

As you can see, relatively few pediatric practices have the resources to achieve full PCMH status. Clearly, the government, insurance companies, and Accountable Care Organizations (ACOs) believe that the PCMH is the future of health care because PCMH practices can provide more efficient care and reduce hospitalizations and ED visits.

Without government or insurance company subsidies, it may be unreasonable to expect that small practices spend the funds and obtain the manpower that may be necessary to provide care coordination services as well as track quality measures. However, noncredentialed V2.0 practices that follow the “Golden Rule of Pediatric Care” can still provide exceptional medical care. While technology can help facilitate care, at the center of any medical home is a quality doctor-patient relationship.

One flaw of the PCMH model is it assumes that most obstacles to care are due to practice/physician inefficacies. In a medical home, patients must have responsibility as well. We all know that the world is full of noncompliant patients who pass on vaccinations, miss appointments, do not take medication as directed, and continue to practice high-risk behaviors. We will continue to educate, inform, and try to help these patients be better patients, but parents and patients likewise must assume responsibility for their actions. Despite the perceived need for pediatric practices to “transform” to be capable of providing full PCMH services, we should always remember that simple is often better, and that providing services according to the golden rule will always suffice, even in a very complicated world.

REFERENCES

1. Pediatric records and a “medical home.” In: Council on Pediatric Practice, American Academy of Pediatrics. Standards of Child Health Care. Evanston, IL: American Academy of Pediatrics; 1967:77.

2. American Academy of Pediatrics Ad Hoc Task Force on Definition of the Medical Home: the medical home. Pediatrics. 1992;90(5):774.

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

4. Medical Home Initiatives for Children With Special Needs Project Advisory Committee. American Academy of Pediatrics. The medical home. Pediatrics. 2002;110(1 pt 1):184-186.

5. National Committee for Quality Assurance (NCQA). NCQA medical homes pass 6,000 mark [news release]. NCQA Web site. http://www.ncqa.org/Newsroom/2013NewsArchives/NewsReleaseSeptember242013.aspx. Published September 24, 2013. Accessed October 8, 2013.

6. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). Joint principles of the patient-centered medical home. http://www.medicalhomeinfo.org/downloads/pdfs/JointStatement.pdf. Published March 2007. Accessed October 2, 2013.

7. Appendix 1: PCMH 2011 scoring. In: National Committee for Quality Assurance (NCQA). Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2011. Washington, DC: National Committee for Quality Assurance (NCQA); 2011.

8. Flores L. Patient Centered Medical Home Guidelines: A Tool to Compare National Programs. Englewood, CO: Medical Group Management Association; 2011.

9. Leu MG, O’Connor KG, Marshall R, Price DT, Klein JD. Pediatricians’ use of health information technology: a national survey. Pediatrics. 2012;130(6):e1441-e1446.

10. Zickafoose JS, Clark SJ, Sakshaug JW, Chen LM, Hollingsworth JM. Readiness of primary care practices for medical home certification. Pediatrics. 2013;131(3):473-482.

Patient-Centered Medical Home Accreditation Programs

National Committee for Quality Assurance (NCQA) PCMH 2011: www.ncqa.org/tabid/631/Default.aspx

Joint Commission PCMH 2011: www.jointcommission.org/accreditation/pchi.aspx

Accreditation Association for Ambulatory Health Care (AAAHC) 2011:

www.aaahc.org/accreditation/primary-care-medical-home/

URAC Patient Centered Health Care Home 2011:

www.urac.org/accreditation-and-measurement/accreditation-programs/all-programs/patient-centered-medical-home-achievement/practice-achievement/

Medical Group Management Association (MGMA) offers a free tool comparing the various accreditation programs:

www.mgma.com/Books/Patient-Centered-Medical-Home-Guidelines/

Abbreviations: PCMH, patient-centered medical home; URAC, Utilization Review Accreditation Commission.

American Academy of Family Physicians. Patient-centered medical home checklist. http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/PCMHChecklist.pdf. Accessed October 2, 2013.

DR SCHUMAN is adjunct associate professor of pediatrics at the Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire. He is also section editor for Pediatrics V2.0 and an editorial advisory board member for Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.