Many people familiar with the concept of the patient-centered medical home (PCMH) might think it is a bit of a pipe dream. But does it have to be that way, or can it become a reality?
The PCMH model of care enables a patient’s primary care physician to be the main point of contact — the avenue through which the patient’s treatment and care is coordinated across the continuum. This kind of care also is notable for availability when and where a patient needs it, and is conveyed in a way the patient can easily understand.
It is no surprise the PCMH is growing in popularity due to its ability to increase cost savings by reducing hospital and emergency department visits, all the while improving patient outcomes.
“PCMH is really a team approach to patient care,” explains Cynthia Arnold, CMPE, PCMH CCE, senior vice president at Kaufman Hall & Associates. “It’s designed to understand individual needs. As additional events happen in the patient’s life, the team makes adjustments in healthcare.”
Arnold notes this model has worked well in many pediatric practices over the years, but its benefits can be realized by other populations and practices as well. Bob Pryor, MD, MPH, pediatrician and senior vice president with Kaufman Hall agrees, sharing how a PCMH can be beneficial for almost any patient.
“PCMH gives a structure, and it’s all about high-quality care,” he says. “The typical physician’s practice involves waiting until someone realizes that they want to see the doctor. The patient calls the clinic to make an appointment, comes in for an episode of care, has their complaint diagnosed, treated, and resolved, and are turned over and back into their milieu. Then, they call when need they need to see the doctor again.”
Instead of this routine, notes Pryor, “PCMH is concerned with answering how we can utilize all of the assets that we have for the patient’s benefit to optimize wellness and well-being, asking what they need in order to live a high-quality life.”
This might mean not expecting the patient to wait until they need a colonoscopy screening, for example, but rather the medical home “contacts the patient and lets them know they’re due for it,” Pryor shares.
Like a Home for Holistic Care
“As physicians start reaching out, people get better and healthier,” Pryor says. “It’s more than just a doctor seeing a sick person. It’s holistic care, taking care of patient needs.”
Pryor notes how, in the past, physicians would discover patient needs largely through home visits. PCMH provides a new “home” for the patient’s medical care since the practice of home visits is nearly obsolete.
Another benefit is the heavy emphasis PCMH places on prevention, which helps people stay healthy. “Acute care visits slide in and out of the context of keeping the patient healthy, and it’s easier to bring the treatment of chronic illness under a PCMH,” Pryor notes.
Proponents of PCMH suggest the model increases the chances of using the primary care physician’s office as the “front door,” rather than the ED.
“When it seems there are no other choices, patients will go to the ED,” Pryor notes. “But using the ED as the front door is less desirable because its overcrowded, designed for emergencies, and one study shows that the same level of care in the ED is 40% more expensive than in the physician’s clinic. Truly, the last place a patient should want to be is in the hospital, since home is safer and more efficient.”
Arnold notes the PCMH model allowed providers to better explain COVID-19 to patients. “For those who had a PCMH, we were able to introduce the concept of the virus into patients’ lives in a way that they understand,” she explains. “COVID showed us how we can easily overwhelm the system when patients continue to arrive at the ED for chronic issues, like asthma.”
Pryor notes two main reasons why patients use the ED for chronic illnesses rather than their physician’s office:
- Available hours of care, especially after hours;
- Lack of insurance, leading to a habit of not considering a physician’s office as part of the routine for stable care.
The trouble with this habit is the resulting lack of a relationship between patients and physicians and no continuity of care.
“With PCMH, the provider develops a relationship,” Arnold shares. “But a patient will typically never see the same doctor twice in the ED. If you have a PCMH, the care team sees you when you’re sick, and you don’t have to start your story at the beginning. They know you, so you just pick up where you’re at.”
The Role of Case Management
PCMH can save case managers time and enable a better process for the patient. But how?
“One way is through chart audits,” Arnold explains. “In the 80s and 90s in family medicine practice, you’d frequently see family charts — and maybe there were even 10 people in that chart. When the doctor looked at it that way, it gave them insight into the care and the daily life of that family. Think about how that impacts the continuity of care for that patient. Today, with electronic records, we have a team of people in the practice to collaborate, and that’s helpful.”
Pryor agrees, adding that not only is it easier for a case manager to access a PCMH patient’s chart, but the discharge process is much smoother.
“When the doctor decides it’s time for the patient to go home, often giving the case manager but 10 minutes’ notice, the case manager has to quickly find out if there is a caregiver in the home and arrange for that, determine if there are social issues, whether there is insulin in the fridge and arrange that, and the list goes on,” he notes. “They are absolute saints.”
“When a doctor discharges a PCMH patient, all of the resources are there,” Pryor adds. “Mental health, nutrition, everything is already bundled, and that can save the case manager time and effort. Plus, no more middle-of-the-night wondering if it all got done, or if there was a gap, or something fell through. The case manager can have peace of mind because the loop gets closed in a way they can measure and feel good about.”
Arnold and Pryor note how PCMH can help decrease overall costs of medical care due to the higher likelihood of preventing illness in the first place, shorten recovery time, and the lower costs associated with diagnosing an illness earlier rather than later.
“Healthcare insurers often strike arrangements with those offering PCMH, and those saved dollars can sometimes help defray the cost of other supports,” Arnold says.
While case managers cannot create a PCMH, they can help promote the concept, Pryor notes. Resources like the National Committee for Quality Assurance publish statistics showing the vast benefits of PCMH. These resources can be shared with the primary care physicians within a hospital system to “talk about how this facilitates case management and how the assets needed to care for the patient are there and more cost effective than you think,” he explains.
Arnold notes that through technology, messaging, and quicker response times, case managers might be able to connect more with PCMHs over the coming years. Pryor predicts case management might be embedded in PCMH practices in the future as well. They acknowledge that while it often takes more staff — nutritionists, mental health professionals, more clinical staff — PCMH is an “aspirational goal that every practice should seek.”