Patient Centered

Medical Home

New Model of Care

Steven E. Waldren, M.D.

 Agenda
• History of Patient Centered Medical
Home (PCMH)

• Current models

• Current evidence

• Challenges in US

Slide 2
 PCMH History
• Concept started in 1960’s by
pediatricians (American Academy of
Pediatrics) for special needs children
• Future of Family Medicine Project
1999 - http://www.futurefamilymed.org
• Multiple Names
– New Model
– TransforMED Model
– Medical Home Model
– Patient Centered Medical Home

Slide 3
 Adoption by Industry
• Patient Centered Primary Care
Collaborative (www.pcpcc.net)
• Over 700 organizations promoting
PCMH
– Purchasers
– Employers
– Health Plans
– Physicians
– Patients

Slide 4
 PCMH Concept
• Joint Principles
– AAFP, AAP, ACP, and AOA
– http://www.pcpcc.net/content/joint-principles-patient-centered-
medical-home
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and integrated
• Quality and safety are hallmarks
• Practice advocates for patient
• Evidence Based Medicine
• Health IT

Slide 5
 PCMH Model: AAFP View

http://www.aafp.org/pcmh

http://www.transformed.com

Slide 6
Slide 7
 Access to Care & Information
• Health care for all
• Same-day appointments
• After-hours access coverage
• Accessible patient information
• Online patient services
• Electronic visits
• Group visits

Slide 8
 Practice-Based Services
• Comprehensive care for both acute
and chronic conditions
• Prevention screening & services
• Surgical procedures
• Ancillary therapeutic and support
services
• Ancillary diagnostic services

Slide 9
 Care Management
• Population management
• Wellness promotion
• Disease prevention
• Chronic disease management
• Patient engagement and education
• Leverages automated technologies

Slide 10
 Care Coordination
• Community-based resources
• Collaborative relationships
– Emergency room
– Hospital care
– Behavioral health
– Maternity care
– Specialist care
– Pharmacy
– Case management
• Care transition

Slide 11
 Quality and Safety
• Evidence based best practices
• Medication management
• Patient satisfaction feedback
• Clinical outcomes analysis
• Quality improvement
• Risk management
• Regulatory compliance

Slide 12
 Practice Management
• Disciplined financial management
• Cost-benefit decision making
• Revenue enhancement
• Optimized coding and billing
• Personnel management
• Facilities management
• Optimized office design/redesign
• Change management

Slide 13
 Health Information Technology
• Electronic medical record
• Electronic orders and reporting
• Electronic prescribing
• Evidenced based decision support
• Population management registry
• Practice Web site
• Patient portal

Slide 14
 Source: Health Affairs April 2010

Slide 15
 Many On-going PCMH Pilots

http://www.pcpcc.net/pcpcc-pilot-projects

Slide 16
 Summary of Evidence

http://www.pcpcc.net/content/pcmh-outcome-evidence-quality

Slide 17
Evidence
 Challenges
• No single “PCMH”
• Requires transformation of the
practice
• Current Health IT is not designed to
support PCMH
• Variability and diversity of practices

Slide 19
 Summary
• Achieving the PCMH will not be
easy, but can be done
• Evidence predicts increased quality
and lower costs
• Work is needed to identify the
highest value components of the
PCMH
• Current policy changes and
industry support is improving ability
to achieve PCMH model
Slide 20