The concept of the “Patient-Centred Medical Home” (PCMH) has been the basis of significant reform of the United States primary healthcare system in recent years. This model of care is based around a patient having an ongoing relationship with one particular primary care doctor, who leads and coordinates their care in the community.
In Australia, key medical organisations are advocating that we too adopt the PCMH model.
The concept was the focus of a symposium held last week in Sydney by the Hospital Alliance for Research Collaboration (HARC) and the Centre for Primary Health Care and Equity (CPHCE) at the University of New South Wales. In this post, CPHCE Director and Professor of General Practice Nick Zwar outlines how the PCHM model works, what it could mean for the way primary healthcare is delivered in Australia, and how New South Wales’ HealthOne initiative is a good start with potential to extend the model further to a “health neighbourhood”. In the second part of the post, Sax Institute Publications Manager Megan Howe reports on the symposium.
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The patient-centred (or person-centred) medical home (PCMH) concept was developed in the United States with the aim of improving the quality, effectiveness and efficiency of primary care. This was in part a response to the disconnected nature of the US health care system and also to substantial variation in the quality of primary care services across the country.
The Irish writer George Bernard Shaw once said “England and America are two countries divided by a common language”. The same could be said about Australia and the US, so it is important to try to clarify some terms. In the US, “primary care” means medical services provided to people in a community setting. The provider may be a family physician, internal medicine specialist, paediatrician or even an obstetrician/gynaecologist. The most analogous service in Australia is general practice, where GPs and their practice teams provide many of these services.
The PCMH model emphasises a patient having an ongoing relationship with a particular doctor (who leads a multidisciplinary practice team) and primary care that is comprehensive, coordinated and accessible, with a focus on safety and quality. The definition is explicitly doctor-centric in that it nominates the physician as team leader and as the main focus of relationship-based continuity of care. Interestingly, this role for the physician seems less contested in the US than in the Australian context.
Achieving the goals of the PCMH model implies a range of organisational and service delivery changes in primary care practices. One of the key requirements is the idea of “empanelment”, to use the US term. This means that the practice or an individual doctor has a defined “panel” of patients for which the practice (or doctor) is accountable.
This is very different to the way primary care currently operates in Australia, where there is no formal patient enrolment system and where the norm has been reactive care, with GPs responding to the needs of any patient who chooses to seek care.
Other features as defined by the Australian Centre for the Medical Home are: comprehensive, whole person care; continuity of care; team-based care; self-management; patient participation; accessibility; excellent clinical information; system-based approach and participation in quality improvement; connections to the ‘medical neighbourhood’; and education and training.
The PCMH concept has gained the support of key medical groups in Australia, including the Australian Medical Association (AMA) and the Royal Australian College of General Practitioners (RACGP), which includes the PCMH as a part of its vision statement for a sustainable healthcare system.
This model of care has also been considered by the Federal government’s Primary Health Care Advisory Group. The report and recommendations from this group are now with Health Minster Sussan Ley.
Australia, like many countries, has long grappled with the issue of how to better integrate care, especially for patients with chronic conditions. But our efforts, including the Coordinated Care trials run in the late 1990s and early 2000s, showed there are no quick or easy fixes and we are yet to find a way to effectively plug the gaps patients often face as they navigate their way around primary, community and secondary care.
To implement the PCMH model in Australia would require incentives to encourage both general practices and patients to adopt a new system of patient enrolment, as well a range of strategies to drive improvements in delivery system design, clinical information systems and self-management support.
I don’t doubt that if Australian general practice was able to adopt the PCMH model, it would lead to improvements in primary care medical services. However, an Australian version of the model would really need to also address the unique federal–state division of health funding, organisation and delivery of health care services in this country.
New South Wales has already seen a shift towards this system of care, with NSW Health’s HealthOne service, which implements many of the features of the PCHM model, in a system that extends the linkages of general practice to other health and social care providers.
There is a great opportunity for a NSW version of the PCMH to not only address quality in general practice, but to build on the HealthOne experience to do something meaningful to improve collaboration (or even better integration) of general practice with state-funded and organised health services. Ideally this needs to include not only community and allied health services, but also hospital services.
There is also potential in NSW to extend the PCMH model further to a “health neighbourhood” that recognises the wide range of health and social services that contribute to good health and health care. The HealthOne model recognises the importance of social care for comprehensively addressing need, so provides a starting point for this work.
Innovative approaches like NSW’s HealthOne are already helping to drive improved integration of care, with the ultimate aim of improved health outcomes in the community. The Patient-Centred Medical Home model, adapted to our local context, may well be the next step we need to take in reforming the way we provide primary healthcare across Australia.
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Recognising the value of primary care
Megan Howe reports:
Before the patient-centred medical home concept was adopted in the US, the role of primary care had become under-appreciated, under-supported and under-resourced, according to family physician and symposium keynote speaker Professor Kevin Grumbach. This resulted in not only a dearth of medical students choosing to become family physicians (or GPs), but an extremely high rate of burnout among doctors who did go into the specialty.
“Primary care was not celebrated. It was in the shadows of the gleaming hospital-based sector,” he said.
Professor Grumbach, the founding director of the Centre for Excellence in Primary Care at the University of California San Francisco School of Medicine, said studies showed that for a GP to do all the necessary preventive care for their patients would take 7.4 hours a day, and to deliver the recommended chronic care services would take an additional 10.6 hours – meaning they would need to spend 18 hours a day to adequately care for their patients.
“The 20th Century model of primary care was not working in the 21st century. The model needed to change,” he said.
The Patient-Centred Medical Home (PCMH) model was adopted under the country’s Affordable Care Act, , which sees patients enrolled or “empanelled” with a primary care practice that coordinates their care. The practice receives a payment per enrolled patient, which helps them employ a team of health professionals to provide comprehensive care suited to their particular community.
Professor Grumbach said the central elements of the model were a change in way primary care was funded − from a fee-for-service model to blended payments, the introduction of a team approach to providing care, a patient-centred approach, and a population-centred approach meaning doctors were proactive in identifying and providing care to all patients who needed it within their population.
“It is a more expensive model of primary care,” he admitted. “The question is whether that investment in primary care is returned through reductions in other costs.”
He suggested the answer appeared to be ‘yes’.
A recently published review of evidence on the impact of patient-centred medical homes on cost and quality found that in 21 of 23 studies that reported on cost, there were reductions in one or more cost measures, while 23 out of the 25 studies that reported on healthcare use showed reductions in one or more healthcare use measures.
An evaluation of the 12-month outcomes of one PCMH showed the model had resulted in improved continuity of care, improved scores for both patient experience and the quality of care, decreased ED visits, and no difference in total costs, with lower costs in the second year.
Professor Grumbach suggested Australia already had a solid base from which to adopt a model like PCMH.
“Australia has a much stronger tradition of general practice and you are starting from a solid position in the health system,” he said.
A “community laboratory”
Networks of patient-centred medical homes could serve as data laboratories, or real-world “community laboratories”, to aggregate data that could be used to improve both practice and population health, Associate Professor Jennifer DeVoe told the Sydney symposium.
Professor DeVoe, a family physician, health service researcher at Oregon Health and Science University, and President of the North American Primary Care Research Group, said the PCMH model had enabled the establishment not just of “medical homes” but of a “village” of practices to share resources and data.
Such research networks did not require “microscopes or laboratories”. Instead, they needed IT infrastructure, engagement and teams to take care of patients and do research, she said.
Professor DeVoe described how the PCMH model had enabled the establishment of a collaborative, practice-based research network called OCHIN, which was now linking data from the electronic patient records of one million patients who were enrolled with 300 primary care sites across 18 states in the US – most of which served vulnerable patient populations.
The network had enabled researchers to study variability in the quality of care provided by different practices, with the top performing practices then used as models or mentors for lower performing practices.
She described how OCHIN had enabled research into the impact of changes in patients’ insurance status, and, with the addition of geocoding, could eventually be used to identify high-risk or uninsured patients who might be eligible for insurance cover but had not signed up for it.
The local experience
The symposium also heard case studies from a number of primary care reform projects already underway in NSW that are using patient-centred medical home principles, including Western NSW Local Health District, which is one of three demonstrator sites for the NSW Integrated Care Strategy.
Program manager Louise Robinson said the strategy aimed to tailor care to the needs of the area’s rural and remote communities, to improve access to care and health outcomes, and had a particular focus on closing the Aboriginal health gap.
Five towns were enrolled in the first wave of the strategy in 2014, and a second wave of five more site were added to the project this year. Each town was tailoring care to suit the specific needs of their community. For example, one town had an aging population with chronic care needs, while another would focus on antenatal and infant care.
Across the first wave sites, 610 patients with chronic care needs had been identified and enrolled. Sites were employing strategies such as medical care and social care “navigators” to ensure patients’ health and social care needs – such as transport or housing – were being met.
Dr Liz Marles, former president of the Royal Australian College of General Practitioners (RACGP), who took part in a panel discussion at the symposium, said all the major GP bodies had endorsed the PCMH model, but the way primary care was currently funded would need to change for the model to be adopted.
“There is a consensus that we want to move to a more blended payment model. I think things are going to change fairly quickly,” she said.
A system of voluntary patient enrolment with practices would also be vital for the PCMH model to be adopted here, she said.
Dr Marles admitted the GP profession was suffering from “change fatigue”, but said there was a will among GPs to “fix up the system”.
“GPs, for quite a long time, have been struggling with the fact that the more complex and difficult patients they have, the less they are going to make as a GP,” she said.
The Hospital Alliance for Research Collaboration HARC links more than 4,000 researchers, health managers, clinicians and policy makers, to drive innovative thinking about emerging challenges in healthcare. It aims to improve health and hospital services through research.
The Centre for Primary Health Care and Equity (CPHCE), based at the University of New South Wales, conducts research, evaluation and development to strengthen primary health care and address health inequities, with the aim of contributing to better, fairer health in the community.
Feature image comes from the Australian Centre for the Medical Home.