In a sense, the medical neighborhood concept attempts to bridge (1) the PCMH model of concentrated coordination responsibility on a primary care team within a single practice with (2) that of large integrated delivery systems that include hundreds of clinicians, multiple facilities, and that function as a single accountable entity jointly responsible for comprehensive care delivery within their boundaries for a given patient. The best existing examples of commercial integrated systems (non-VA or Department of Defense) are staff/group model health plans such as Kaiser Permanente that deliver comprehensive care for a specified patient panel in return for a fixed premium. Because integrated delivery systems do not exist in most markets, medical neighborhoods may offer communities an avenue for improving integration of care delivery on a smaller scale and possibly, in a more patient-centered way. Moreover, even existing integrated delivery systems may fall short of the care coordination ideal, for services delivered both within and outside their boundaries, if their patients do not have an identifiable medical home clinician within the system to help them navigate care processes and synthesize information from disparate sources. Integrated delivery systems may thus also improve internal processes for coordination based on the medical neighborhood model.
The collective patients affiliated with each medical home are at the center of the neighborhood, figuratively and literally driving decision-making through their expressed preferences and shared decision-making. Patients would also be expected to accept certain responsibilities as the primary agent in their own care, including clearly identifying the clinicians they consider their primary providers, and being consistent in those decisions when they communicate with their providers and insurers. Patients would select their medical home, and then the PCMH would, in concert with the patient, identify peers who would serve as “neighbors” and partners in care. Mutual acknowledgement of care relationships and explicit articulation of each clinician’s role will help align the expectations of all involved and clarify lines of accountability.
A task as complex as care coordination requires sets of overlapping expectations and responsibilities among different actors. The primary care model as described by Starfield and the Institute of Medicine6,7
emphasizes the role of the primary care clinician as part of a practice team—to provide first-contact, longitudinal, and whole-person care; to “triage” patients and arrange for services from other providers as they require; and to coordinate the patient’s overall health care—but is less explicit about patient (and caregiver) and neighbor responsibilities. Table delineates the coordination activities within the medical home and illustrates how the medical home must rely upon active participation from patients and neighbors to achieve coordinated care. Where the same or similar tasks are shared by more than one actor, the bolded item indicates where the greatest responsibility falls.
Responsibilities of Medical Homes, Patients, and Medical Neighbors
Two primary themes emerge from this conceptual framework: that of Reciprocity of responsibilities and that of the importance of Reliability in an effective neighborhood. Reciprocity of responsibilities acknowledges that care coordination is an inherently human activity requiring personal interactions, some of which will be symmetric (a medical home and medical neighbor are each responsible for telling the other when they make a change to ongoing therapy) and some of which will be asymmetric (every clinician is responsible for eliciting a patient’s care preferences and patients are responsible for communicating those preferences in a complete and honest manner). Reciprocity implies that the coordination effort exerted by one actor may not be effective in the absence of the reciprocal effort by another actor. For example, the PCMH may re-engineer practice workflows to provide first-contact and longitudinal care, but if an informed patient insists on seeking first-contact care in an emergency department or “doctor shopping,” the medical home’s efforts to improve access will be for naught.
Reliability of the neighborhood in achieving coordinated care means first acknowledging that time, energy, and resources are limited, making it risky to depend on any single actor to perform all necessary coordination tasks. In the patient safety field, shared responsibilities—such as multiple clinicians checking on the identification of a presumed surgical patient before operating—help prevent adverse events, albeit with increased effort and associated costs.8
Similarly, spreading the responsibility across the PCMH and neighbors for coordination tasks could help minimize the degree to which those tasks “fall through the cracks” of care. Neither reciprocity of coordination tasks nor processes that ensure reliability of the neighborhood undermines the central role that the medical home plays (for example, although both the PCMH and neighbor are responsible for eliciting patients’ care preferences, the PCMH bears the primary responsibility), but rather they make clear the critical inter-dependencies between actors.
Compatible electronic information systems that are shared by all members of the neighborhood would greatly facilitate communication9
and are an important component for success. It is important that such systems support all critical coordination tasks, particularly those involving shared decision-making; most current systems do not10
. In addition, the desired timing of many actions in Table will likely vary across care situations and be dependent on community standards.