by COLLEEN CREAMER
For VerusMed
With the number of medical students entering generalized medicine waning along with funds for health care, the “patient-centered medical home” (PCMH) might not only become a piece in health care reform, but it could also become a necessity, proponents say.
“We are not going to have enough medical students in the future to meet the aging population,” said Dr. Earlexia Norwood, physician-in-residence at the PCMH pilot project in the Henry Ford Medical Center, a sector of the Henry Ford Health System in Detroit.
The primary shift from the traditional model to PCMH is delegation. At its core, the model is a hub of services with the physician at the center, with all arms of the PCMH communicating with one another. It was initially developed by the American Academy of Pediatrics in 1967 to enhance the complex care of children with special needs; the expectation is better and less expensive health care.
In the PCMH model, the doctor, often mired in administrative duties that do not best use a physician’s skills, is freed up to do more patient care. Duties that can be handled by trained non-physician care providers such as nurses, pharmacists, medical assistants and case managers are handed off to the appropriate team member. Technology is leveraged to communicate between the varying providers.
“The primary care doctor is not necessarily the doctor that may be considered the home of the patients,” Norwood said. “It could be their oncologist or their gynecologist.”
Some of the principles of a PCMH include having a personal physician as well as a physician-directed team, an orientation geared to the “whole person” and coordinated care emphasizing quality and safety, Norwood said. By streamlining and implementing preventative measures, Norwood added, PCMHs could reduce costs, provide better quality health care, reduce racial health disparities and prevent disease better.
A critical component of PCMH is the clinical pharmacist, who becomes directly involved when a patient is on seven or more medications or on five drugs with at least one being high-risk. In practice, the clinical pharmacist looks at the doctor’s schedule two weeks out, goes through a patient’s record and determines whether he or she fits the category.
“The patient is then reviewed in detail and then the clinical pharmacist determines what clinical information they need to provide for that patient and what needs to change,” Norwood said.
Data from the Henry Ford project showed that 60 percent of the drug interventions tracked were drug therapy changes that improved efficacy, and 40 percent of the interventions were drug changes that improved safety.
Currently, physicians allot themselves roughly 15-minute slots for each patient and, consequently, are unable to effectively handle extra issues the patient might come in with, Norwood said.
“So you need to move [the patient] through quickly, so there isn’t an incentive to do everything that Mrs. Jones needs to have done at that visit because of generating numbers,” Norwood said.
Norwood’s partner at Henry Ford, clinical pharmacy specialist Dr. Vanita Pindolia, noted that savings in time and cost have been demonstrated at their facility by using PCMH.
“Keep this number in mind,” Pindolia said. “Our average time per case is two to two and a half hours (per visit). … The majority of that time is with that patient.”
Pindolia referred to 2006 data from their pilot project to make the case for PCMH’s cost effectiveness.
“We found that those who accepted (entry) compared to those who declined had a steeper lowering trend in both their prescription costs and their medical costs,” Pindolia said.
The PCMH model, Norwood said, works through what are referred to as “floors.” Information technology would be in the basement, but there is a “huge front yard” that consists of all the community resources that aid in health and prevention such as nutrition and exercise programs. The ground floor, which deals with healthy individuals, would offer more basic services such as self-care kiosks; “e-visits” for specific, non-threatening complaints; preventive measures; and physician, registered nurse or physician assistant visits.
The second floor cares for patients with moderate, but chronic illnesses. Services might include group visits with “mid-level” providers, clinical practice guidelines and planned care.
The third and fourth floors are the more critical levels where case management and polypharmacy management is needed for complex care and, possibly, palliative care. On those floors, the primary care doctor is more involved in the day-to-day management of patient care.
“What we know is that when we have patients that are reasonably healthy, there are different ways we can care for them outside of having a one-on-one, come into the office every time you need to see me,” said Norwood.
Because PCMHs track the patient in good and ill health, Norwood maintained they provide better quality because they are not “episodic” driven. She added that regulatory demands on doctors by the Centers for Medicare & Medicaid Services cannot be met under the current model, and with health care costs rising, streamlined ways of dispensing care will have to become a part of a new sustainable health care model.
