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  • Patient-Centered Medical HomesPatient-Centered Medical Homes How Public Health Practitioners Can Support PCMHs Background A strong influence on health outcomes are social determinants
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Patient-Centered Medical Homes How Public Health Practitioners Can Support PCMHs Background A strong influence on health outcomes are social determinants of health (SDOH), which are factors that are outside of the health care system such as education and income levels. 1, 2, 3 SDOH issues are an important consideration when determining how to best integrate clinical and community strategies to produce better health. The current separate and isolated models of care delivery can be more effective by integrating multiple strategies—clinical, mental health, social, economic, education, and community—within a single population or health care system, using a team-based and whole person approach. 4 Integrated models include Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). Many private and public systems have chosen to adopt PCMHs as a health care delivery strategy. PCMHs are led by the primary care provider and coordinate care across the health care community. The patient’s full scope of health care needs, including prevention, is the facilitator of all care service. This is irrespective of the number of providers or where the patient receives care. 5 The following overview of PCMHs includes suggestions on how public health practitioners can support PCMH in prevention work and additional resources. Description of a PCMH What is a PCMH? A PCMH is a model of care that strengthens the clinical-patient relationship by replacing episodic care with coordinated, whole person, and long term care. The primary care clinician leads a team of clinical and community health providers who take collective responsibility for patient care. They coordinate care for the patient’s health needs and arrange for appropriate care with other qualified health services. 6 PCMH Defining Principles The Joint Principles of PCHM include the following: • Personal physician —Every patient has a continuous and consistent relationship with a physician, who is the patient’s first contact and coordinates all care. • Physician-directed medical practice—The personal physician leads a team who take collective responsibility for the patient’s care. • Whole person orientation—The personal physician takes responsibility for providing and coordinating all acute, chronic, and end-of-life care, as well as preventive services for the patient. • Care is coordinated and integrated —All sectors of the health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) work synergistically to deliver care in a culturally and linguistically appropriate way. • Quality and safety — Care is evidence-based and health information technology (IT) is strategically used to support optimal patient care. Physician practices complete a PCMH voluntary accreditation process to demonstrate PCMH capability, serve as the patient’s advocate within the health care system and “The social determinants of health are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” 1

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Page 1: Patient-Centered Medical HomesPatient-Centered Medical Homes How Public Health Practitioners Can Support PCMHs Background A strong influence on health outcomes are social determinants

Patient-Centered Medical Homes How Public Health Practitioners Can Support PCMHs

Background Astronginfluenceonhealthoutcomesaresocialdeterminantsofhealth(SDOH),whicharefactorsthatareoutsideofthehealthcaresystemsuchaseducationandincomelevels.1,2,3SDOHissuesareanimportantconsiderationwhendetermininghowtobestintegrateclinicalandcommunitystrategiestoproducebetterhealth.Thecurrentseparateandisolatedmodelsofcaredeliverycanbemoreeffectivebyintegratingmultiplestrategies—clinical,mentalhealth,social,economic,education,andcommunity—withinasinglepopulationorhealthcaresystem,usingateam-basedandwholepersonapproach.4IntegratedmodelsincludePatient-CenteredMedicalHomes(PCMHs)andAccountableCareOrganizations(ACOs).ManyprivateandpublicsystemshavechosentoadoptPCMHsasahealthcaredeliverystrategy.PCMHsareledbytheprimarycareproviderandcoordinatecareacrossthehealthcarecommunity.Thepatient’sfullscopeofhealthcareneeds,includingprevention,isthefacilitatorofallcareservice.Thisisirrespectiveofthenumberofprovidersorwherethepatientreceivescare.5ThefollowingoverviewofPCMHsincludessuggestionsonhowpublichealthpractitionerscansupportPCMHinpreventionworkandadditionalresources.Description of a PCMH WhatisaPCMH?APCMHisamodelofcarethatstrengthenstheclinical-patientrelationshipbyreplacingepisodiccarewithcoordinated,wholeperson,andlongtermcare.Theprimarycareclinicianleadsateamofclinicalandcommunityhealthproviderswhotakecollectiveresponsibilityforpatientcare.Theycoordinatecareforthepatient’shealthneedsandarrangeforappropriatecarewithotherqualifiedhealthservices.6

PCMHDefiningPrinciplesTheJointPrinciplesofPCHMincludethefollowing:

• Personalphysician—Everypatienthasacontinuousandconsistentrelationshipwithaphysician,whoisthepatient’sfirstcontactandcoordinatesallcare.

• Physician-directedmedicalpractice—Thepersonalphysicianleadsateamwhotakecollectiveresponsibilityforthepatient’scare.

• Wholepersonorientation—Thepersonalphysiciantakesresponsibilityforprovidingandcoordinatingallacute,chronic,andend-of-lifecare,aswellaspreventiveservicesforthepatient.

• Careiscoordinatedandintegrated—Allsectorsofthehealthcaresystem(e.g.,subspecialtycare,hospitals,homehealthagencies,nursinghomes)andthepatient’scommunity(e.g.,family,publicandprivatecommunity-basedservices)worksynergisticallytodelivercareinaculturallyandlinguisticallyappropriateway.

• Qualityandsafety—Careisevidence-basedandhealthinformationtechnology(IT)isstrategicallyusedtosupportoptimalpatientcare.PhysicianpracticescompleteaPCMHvoluntaryaccreditationprocesstodemonstratePCMHcapability,serveasthepatient’sadvocatewithinthehealthcaresystemand

“Thesocialdeterminantsofhealtharethecircumstancesinwhichpeopleareborn,growup,live,work,andage,aswellasthesystemsputinplacetodealwithillness.Thesecircumstancesareinturnshapedbyawidersetofforces:economics,socialpolicies,andpolitics.”1

Page 2: Patient-Centered Medical HomesPatient-Centered Medical Homes How Public Health Practitioners Can Support PCMHs Background A strong influence on health outcomes are social determinants

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community,andareaccountabletocoordinatecare.Patientsandtheirfamiliesareengagedincontinuousqualityimprovementactivitiesandactivelyparticipateindecisionmaking.

• Enhancedaccess—Careisavailablewithopenscheduling,expandedhours,andoptionsforcommunicationbetweenpatients,theirpersonalphysician,andteam.

• Payment—ThepaymentstructureshouldreflectthevaluethatapatientreceivesfromaPCMH.Itprovidesreimbursementforcaremanagementandcoordinationthathappensoutsideoftheprimarycaregiversoffice.Paymentalsoallowsforfee-for-servicereimbursementforofficevisitsandtakesintoconsiderationthevariedneedsofeachpatient.Paymentshouldsupportimprovedcommunicationthroughtelephone,securee-mailconsultation,andadoptionofstrategichealthIT(e.g.,electronicmedicalrecords,electronicreminders)forqualityimprovement,coordinationofservices,andremotemonitoringofclinicaldata.7

How Public Health Practitioners Can Support PCMHs • Buildstrongrelationshipswithphysiciansandpractices:Publichealthpractitionerscanbuildtrusting

relationshipswiththePCMHteamtoensurethesuccessfulcoordinationofpublichealthserviceswithclinicalservicesthatarebothessentialtoapatient’shealthandwell-being.BycollaboratingwithphysiciansinaPCMHorsimilarteameffort,publichealthpractitionerscanalsoaddahealthequitylenstoincreaseawarenessofSDOHtoimprovehealthoutcomes.

• Serveasacommunityconnector:PublichealthpractitionerscanfacilitatePCMHteamconnectionstocommunity-basedorganizations,services,andcommunitynetworksthatareimportanttopatientcare.Practitionershaveestablishedrelationshipswithcommunity-basedserviceprovidersthatfocusonhealtheducationandaccesstohealthyfood,physicalactivity,wellnessprograms,mentalhealth,andsubstanceabuseservices.Practitionerscanhelppatients’accessadditionalresourcestocomplimentclinicalcare.

• Engagehealthcareextenders:Publichealthpractitionerscanengagehealthcareextenders,suchascommunityhealthworkers,whohaverelationshipswithcommunitiesexperiencinghealthdisparities,whichare“gapsinthequalityofhealthandhealthcareacrossracial,ethnic,sexualorientationandsocioeconomicgroups.”8HealthcareextenderscanprovidevaluableinsightintocommunitiesthatarelinguisticallyorculturallychallengingtothePCMHteamandaddressbarrierscreatedbySDOH.

• Demonstratethevalueofpopulationhealthandpreventionstrategies:PublichealthpractitionerscanprovideinformationanddatatothePCMHsteamonpublichealthsurveillanceorfromacommunityhealthneedsassessmenttocreateabroaderunderstandingbycaregiversthatimprovinghealthismorethanprovidinghealthservicestoanindividualpatient.Practitionerscanprovideinformationonprimary(preventdevelopinghealthproblem),secondary(atriskfordevelopinghealthproblem),andtertiary(establishedhealthproblem)9preventionactivitiesandprogramsthatfocusonpreventivescreening,healthyeating,physicalactivity,tobaccocessation,healthyfamilies,childwellness,immunizations,mentalhealth,substanceabuse,andsafetyandothercorefunctionsofpublichealth.3

Resources

• NationalCommitteeonQualityAssurance• AgencyforHealthcareResearchandQuality

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• PatiententeredPrimaryCareCollaborative• NationalAcademyforStateHealthPolicy• JointPrincipalsofthePatient-CenteredMedicalHome(March,2007)(p.2)

References 1. SocialDeterminatesofHealth:KeyConcepts,WorldHealthOrganizationWebsite.

http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/index.html.AccessedApril22,2014.

2. TheRobertGrahamCenter,ThePatientCenteredMedicalHome:History,SevenCoreFeatures,EvidenceandTransformationalChange,Washington,DC:CenterforPolicyStudiesinFamilyPracticeandPrimaryCare;2007.http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2007/rgcmo-medical-home.Par.0001.File.tmp/rgcmo-medical-home.pdf.AccessedDecember4,2013.

3. GargA,JackB,ZuckermanB,Addressingthesocialdeterminantsofhealthwithinthepatient-centeredmedicalhome:lessonsfrompediatrics,JAMA.2013;309(19):2001-2002.

4. FerranteJM,BalasubramannianBA,HudsonSV,CrabtreeBF.Principalsofthepatient-centeredmedicalhomeandpreventativesservicesdelivery.AnnalsofFamilyMedicine.2010;8(2):108-116.http://www.annfammed.org/content/8/2/108.long.AccessedApril22,2014.

5. ComprehensivePrimaryCareInitiative.CenterforMedicaidandMedicareInnovationWebsite.http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/.AccessedDecember4,2013.

6. NationalCommitteeonQualityAssurance.NCQAPatient-CenteredMedicalHome2011:HealthCarethatRevolvesAroundYou.http://www.ncqa.org/Portals/0/PCMH2011withCAHPSInsert.pdf.AccessedDecember4,2013.

7. Patient-CenteredPrimaryCareCollaborative.JointPrincipalsofthePatient-CenteredMedicalHomeWebsite.http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdfAccessedDecember4,2013.

8. MedicalNews.Whatarehealthdisparities?Website.http://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx.AccessedDecember9,2013.

9. MedicalNews.Whatarehealthdisparities?Website.http://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx

.AccessedDecember9,2013.

http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/index.html
http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2007/rgcmo-medical-home.Par.0001.File.tmp/rgcmo-medical-home.pdf
http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2007/rgcmo-medical-home.Par.0001.File.tmp/rgcmo-medical-home.pdf
http://www.annfammed.org/content/8/2/108.long
http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/
http://www.ncqa.org/Portals/0/PCMH2011 withCAHPSInsert.pdf
http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf
http://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx
http://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx
ttp://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx
ttp://www.news-medical.net/health/Health-Disparities-What-are-Health-Disparities.aspx

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