Medical Home - History

History

The concept of the "medical home" has evolved since introduction of the terminology by the American Academy of Pediatrics in 1967, which was envisioned at the time as a central source for all the medical information about a child, especially those with special needs. Efforts by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician, to pursue new approaches to improve early childhood development in Hawaii in the 1980s laid the groundwork for an Academy policy statement in 1992 that defined a medical home largely the way Sia conceived it: a strategy for delivering the family-centered, comprehensive, continuous and coordinated care that all infants and children deserve. In 2002, the organization expanded and operationalized the definition.

In 2002, seven U.S. national family medicine organizations created the Future of Family Medicine project to "transform and renew the specialty of family medicine." Among the recommendations of the project was that every American should have a "personal medical home" through which to receive his or her acute, chronic, and preventive services. The services should be "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians."

As of 2004, one study estimated that if the Future of Family Medicine recommendations were followed (including implementation of personal medical homes), "health care costs would likely decrease by 5.6%, resulting in national savings of 67 billion dollars per year, with an improvement in the quality of the health care provided." A review of the literature published the same year determined that medical homes are "associated with better health, ... with lower overall costs of care and with reductions in disparities in health."

By 2005, the American College of Physicians had developed an "advanced medical home" model. The model involved the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, medical care plans, "enhanced and convenient" access to care, quantitative indicators of quality, health information technology, and feedback on performance. Payment reform was recognized as important to implement the model.

IBM and other organizations started the Patient-Centered Primary Care Collaborative in 2006 to promote the medical home model. As of 2009, its membership included "some 500 large employers, insurers, consumer groups, and doctors."

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association — the largest primary care physician organizations in the United States — released the Joint Principles of the Patient-Centered Medical Home. The principles listed were:

• 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: Care is coordinated and/or integrated between complex health care systems, for example across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient’s loved ones and community-based services. This goal can be attained though the utilization of registries, health information technology and exchanges, ensuring patients receive culturally and linguistically appropriate care (Patient-Centered Primary Care Collaborative).

• Quality and safety - Partnerships between the patient, physicians and their family are an integral part of the medical home. Practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care - Guide decision making based on evidence based medicine and with the use of decision-support tools - Physician’s voluntary engagement in performance measurements to continuously gauge quality improvement - Patients are involved in decision making and provide feedback to determine if their expectations are met - Utilization of informational technology to ensure optimum patient care, performance measurement, patient education, and enhanced communication - At the practice level, patients and their families participate in quality improvement activities - (Patient-Centered Primary Care Collaborative).

• Enhanced access to care is available through open scheduling and extended hours and new options for (Balara & Harper) (Patient-Centered Primary Care Collaborative).

• Payment must "appropriately recognize the added value provided to patients who have a patient-centered medical home." - Payment should reflect the time physician and non-physician staff spend doing patient-centered care management work outside the face-to-face visit - Services involved with coordination of care should be paid for - It should support measurement of quality and efficiency with the use and adoption of health information technology (Batesm & Bitton, 2010) - Enhanced communication should be supported - It should value the time physicians spend using technology for the monitoring of clinical data - Payments for care management services should not result in deduction in payments for face-to-face service - Payment “should recognize case mix differences in the patient population being treated within the practice” - It should allow physicians to share in the savings from reduced hospitalizations - It should allow for additional compensation for achieving measurable and continuous quality improvements

A survey of 3,535 U.S. adults released in 2007 found that 27% of the respondents reported having "four indicators of a medical home." Furthermore, having a medical home was associated with better access to care, more preventive screenings, higher quality of care, and fewer racial and ethnic disparities.

Important 2008–2010 developments concerning medical homes included:

• The Accreditation Association for Ambulatory Health Care (AAAHC) began accrediting medical homes in 2009 and is the only accrediting body to conduct on-site survey for organizations seeking Medical Home accreditation.
• The National Committee for Quality Assurance released Physician Practice Connections–Patient-Centered Medical Home (PPC-PCMH), a set of voluntary standards for the recognition of physician practices as medical homes.
• In answering a 2008 survey from the American Academy of Family Physicians, then-presidential candidate Barack Obama wrote "I support the concept of a patient-centered medical home" and that as president he would "encourage and provide appropriate payment for providers who implement the medical home model".
• The New England Journal of Medicine published recommendations for the success of medical homes that included increased sharing of information across health care providers, the broadening of performance measures, and the establishment of payment systems that share savings with the physicians involved.
• Guidance for patients and providers on operationalizing the Joint Principles was made available.
• The American Medical Association expressed support for the Joint Principles.
• A coalition of "consumer, labor and health care advocacy groups" released nine principles that "allow for evaluation of the medical home concept from a patient perspective."
• Initial findings of a medical home national demonstration project of the American Academy of Family Physicians were made available in 2009. A final report on the project, which began in 2006 at 36 sites, will be published in 2010.
• By 2009, 20 bills in 10 states had been introduced to promote medical homes.
• In 2010, 7 key health information technology domains were identified as necessary for the success of the PCMH model: telehealth, measurement of quality and efficiency, care transitions, personal health records, and, most important, registries, team care, and clinical decision support for chronic diseases.
• On January 31, 2011, the National Committee for Quality Assurance (NCQA) released new standards for its Patient-Centered Medical Home (PCMH) program. The new standards call on medical practices to be more patient-centered, and reinforce federal “meaningful use” incentives for primary care practices to adopt health information technology.