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The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare.
The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care.
The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change.
Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.
The online version of this article (doi:10.1007/s11606-010-1291-3) contains supplementary material, which is available to authorized users.
The patient-centered medical home (PCMH) is emerging as a centerpiece of efforts to reform healthcare in the US and to establish a primary care basis for improving the value of healthcare.1–4 In contrast to currently beleaguered US primary care,5–9 what a PCMH looks like is not known outside of ongoing demonstration projects and a small number of practices that have sought to be recognized according to new standards set by the National Committee for Quality Assurance (NCQA).10–14 In contrast, the benefits of primary care for people and societies are well-established.15–19 Furthermore, the process and intended and unintended consequences20–25 of transforming current practices into patient-centered medical homes are only beginning to be understood.26
Therefore, in this paper we carry out the following:
We define the PCMH as a team of people embedded in the community who seek to improve the health and healing of the people in that community. They work to optimize the fundamental attributes of primary care combined with evolving new ideas about organizing and developing practice and changing the larger health care and reimbursement systems. Unlike more narrowly focused ways of organizing the delivery of commodities of healthcare, the PCMH aims to personalize, prioritize and integrate care to improve the health of whole people, families, communities and populations.
Thus, the PCMH consists of the following:
The PCMH concept links new approaches to health care organization1,27–34 with the well-established primary care function for improving the health of people and populations.35 Below we overview each of these four aspects of the PCMH.
Table 1 shows the core attributes of primary care are: first contact accessibility, comprehensiveness, integration & coordination, and relationships involving sustained partnerships over time.15,36–38
First contact access in the PCMH increasingly involves distance and asynchronous communication and self-care, in addition to face-to-face contact with practice members and partners.39–41 Comprehensiveness includes provision of services that account for the majority of patient needs, including mental health42–44 and care of often multimorbid45–47 chronic illnesses.48–53 Coordination involves guiding access to more narrowly focused care when needed;38 integration of care involves optimizing and prioritizing delivery of needed services across acute and chronic illness, prevention, mental health and family care.54 The PCMH emphasizes functional linkages with community organizations and with other healthcare entities such as hospitals, specialists, other service providers, urgent care, etc.39,55–57 Sustained partnership involves developing relationships58 that are patient-centered59–62 and grounded in local knowledge of the family and community.15
Health care systems with a primary care focus have better quality,63 lower cost,63–65 less inequality in health care and health,16,18,66–69 and better population health16,65,70 when compared with systems based on other approaches to health care.
One of the critical and under-appreciated attributes of primary care is its flexibility in adapting to different sociopolitical climates, populations, communities, individual patients and available clinicians and practice workers.71 Indeed, in international comparisons, Meads has identified a typology of 6 different manifestations of primary care,72 all of which are manifested to some degree in different parts of the pluralistic US healthcare market.
The PCMH moves beyond primary care as it is practiced now, to include new approaches to organizing practice to enhance its responsiveness to local patient needs. In various manifestations currently being tried,14,31,40,73–75 these include diverse instrumental elements such as same-day appointment, electronic visits, group visits, disease registries and management, greater patient engagement, care coordination, new collaborative relationships, team-based care, quality and safety initiatives, electronic prescribing and medical records. Many of these changes grow out of the recommendations of the Institute of Medicine for reforming health care,32,76 from learning collaboratives sponsored by the Institute for Healthcare Improvement77,78 and others.51,79,80
Recent evidence shows that the large majority of primary care practices are not ready to become PCMHs.11,12,81–83 Experience from the first PCMH National Demonstration Project26 shows that even for highly motivated practices, the transformation to a PCMH represents a developmental process that necessitates practice work on internal capabilities.84 These capabilities consist of core structures and processes, adaptive reserve, and attentive connections to the local environment the relationship infrastructure, an aligned management model, and leadership development.85 In most practices the intense effort to incorporate multiple improvements and changes in core processes and relationships reveals deficits in the practice’s adaptive reserve that must be addressed as the transformation process proceeds. Thus, the transformation of primary care into PCMHs is best understood as a developmental process, with stops, starts, backslides, leaps and challenges.85 If the PCMH is to be sustainable and to evolve in an environment of continual change, primary care practices must enhance their robustness and resilience and foster connections in order to be locally responsive.85
Primary care does not operate in isolation, and one of its core functions is the effective and efficient integration of care both vertically (within disease categories) and horizontally (across the diverse needs of peoples, communities and populations).86,87 In light of the co-evolving nature of the PCMH and the healthcare system within which it functions, the need for reform of the medical “neighborhood” increasingly is recognized,55 in particular to help primary care to be more effective at integrating and prioritizing care.54,88
Primary care in the US in under-resourced compared to specialty care.70,89,90 Blended payment91,92 and other reimbursement reforms29,93–96 have been proposed to redistribute resources toward the primary care function that provides the greatest value. Various minor reforms ranging from paying care management fees to reimbursing for specific components of the PCMH are included and are being evaluated in a number of the ongoing PCMH demonstrations and pilot projects.14,74 Involving patients in practice and healthcare system governance represents a particularly promising innovation.39,97,98
A 2007 joint statement99 of four physician organizations whose members constitute the majority of primary care clinicians in the US identifies seven principles of the PCMH. These are summarized in Table 2.
Similar to our definition of the PCMH, the joint principles specifically include some of the fundamental tenets of primary care (access, coordination/integration), plus new ways of organizing practice (enhanced access, physician-directed team-oriented practice, focus on quality and safety), plus health care and reimbursement system changes (payment that recognizes added value). Other aspects of primary care are subsumed under other titles (such as relationship and comprehensiveness under personal physician and whole person orientation, which is similar to comprehensiveness).
The joint principles build on other operationalizations of the primary care and medical home concepts.1–4,13,27,28,30,35,40,57,60,61,100–111 They assume the well-established primary care function61 in the same way that the principles of primary care assume appropriate and adequate disease-specific quality of care and supportive systems and reimbursement.112
The principles are evolving in their on-the-ground operationalization in diverse contexts in hundreds of PCMH demonstrations ongoing around the US,14,113 as new collaborators are brought to the partnership114 and as ongoing evaluations bring forth new evidence of intended and unintended consequences.4,12,26,39,71,73,75,83–85,97,105,115–129
The rationale and goals for measuring the PCMH are diverse, and include evaluation of baseline status or changes, guiding development and improvement through a change process, certifing of practices as PCMHs, guiding reimbursement or investment, and generating new knowledge.
The goal, as well as the setting and available resources, guide many of the decisions for measuring PCMH. For example, in evaluating the first National Demonstration Project of the PCMH,75,118,130 our goals were to provide a rigorous evaluation that generated transportable new knowledge about the process of practice change73,84,85,116 and the outcome for practices73,116 and patients.119 We also sought to provide ongoing feedback to implementers to guide their change process and to inform policy and practice.26,75,85,117,121 The diverse practice and system settings across the US provided challenges; measurement resources were limited but more substantial than available for individual practices or for most systems.
In this setting, we chose a multimethod approach118,131–138 to foster understanding of meaning and context while also testing a priori and emerging hypotheses—that is, we measured and analyzed both numbers and narratives. We attempted to measure the instrumental aspects of the PCMH as envisioned by the implementation group,40 and processes and outcomes from the perspectives of change facilitators, practice members, patients, and medical and financial records.
In other settings, goals and measurement are narrower. Many practices attempting to be recognized as PCMHs are only measuring NCQA criteria. Others attempting an iterative practice improvement process emphasize change processes and outcomes for the practice and patient.115 Systems deciding on investment in PCMH conversions tend to emphasize cost and utilization outcomes, but also sometimes measure quality and the experience of staff and patients.39,56,97
Despite the diversity of purposes, situations and resources, some principles for PCMH measurement can be specified:
The National Committee for Quality Assurance’s Physician Practice Connections®—Patient-Centered Medical Home™ tool160 is a practice self-report measure and has become the de facto standard used by many demonstrations to judge “medical homeness.” It is being used in most ongoing demonstrations.14 The NCQA PPC®-PCMH™is based on considerable prior work110,161–165 and attempts to emphasize measurement reliability and practicality.160 It assesses nine standards: access and communication, patient tracking and registries, care management, patient self-management support, electronic prescribing, test tracking, referral tracking, performance reporting and improvement, and advanced electronic communications.160 The three-level scoring implicitly acknowledges that, for most practices, meeting these reporting standards will be a staged process.
The PPC®-PCMH™ contains 166 items, of which 46% assess practice report of functions that require use of some type of electronic information technology, 14% assess care for three specific chronic diseases the practice identifies as important to their patient panel, 13% reflect systems for coordinating care, 9% assess accessibility, 5% relate to performance reporting, and 4% are about tools for organizing clinical data. Use of non-physician staff and collection of data on patient’s experience of care are each reflected in 2% of items, and 1% of items represent each domain of preventive service delivery, continuity of care and patient communication preferences.166
Criticisms of the NCQA’s measure4,26,124,166,167 relate to the balance of items compared to the valued domains of primary care, the degree to which the items are measured by the most appropriate perspective, the degree to which the items distinguish between high and low quality primary care, the lack of a patient perspective, and the opportunity costs and potential unintended consequences of the PCMH measurement and recognition process.
On June 15, 2009 the NCQA articulated a “Planned Evolution of PPC-PCMH Requirements.”168 This document states an interest in “understanding better how to assess patient-centeredness and experience as well as quality and cost outcomes,” and expresses an interest in assessing patient’s experience of the PCMH. It identifies a need for “standards designed to realize quality and cost gains achieved through better coordination and integration across settings.” The document also notes the need to capture “relationships to various types of community organizations,” and to “recognize the role of providers other than physicians.”
There are a number of measures that assess important aspects of primary care that can be a source of items for comprehensive measurement of the PCMH.15,36,84,116,118,119 Many of these domains are assessed from the patient point of view by the Primary Care Assessment Survey (PCAS)169 and the Ambulatory Care Experiences Survey (ACES)170 by Safran, the Primary Care Assessment Tool (PCAT)171,172 by Starfield, the Components of Primary Care Instrument (CPCI)173–175 by Flocke, and the Clinician-Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS)176 by the Agency for Healthcare Research and Quality. The PCAT and the CAHPS include versions for adults and children. The Assessment of Chronic Illness Care (ACIC)177 assesses system support relevant to the Chronic Care Model.51,178,179 The Medical Home Index (MHI) was developed specifically to assess six domains of the pediatric PCMH (organizational capacity, chronic condition management, care coordination, community outreach, data management and quality improvement).180 John Howie has created an important patient-level outcome measure of the effectiveness of care. The Patient Enablement Instrument (PEI) assesses the degree to which patients are better able to cope with life, understand and cope with their illness, and keep themselves healthy as a result of their healthcare.181–183 In addition to further work in developing a Consultation And Relational Empathy (CARE) measure,184 Howie’s group has taken the interesting step of adding both relationship aspects and time to the PEI to create the Consultation Quality Index (CQI), based on empirical evidence that time is an essential for enablement, relationship development and patient-centered care.185–187
These different measures and others provide a wealth of possibilities for bringing the patient perspective and the core feature of primary care into PCMH assessment and recognition. The patient perspective assesses different domains that quality measures often overlook.188 While the self-report aspect of the NCQA measure has inherent biases, reliably gathering the patient perspective requires attention to selection factors and sample size as well as measurement reliability and validity. More than a research standard, practical considerations and an ability to understand local adaption are vital if measures are to be widely applied to judge the PCMH qualifications of practices.
Table 3 depicts the components of the PCMH as articulated by the Joint Principles of the PCMH,99 and the related domains of the primary care function, based on definitions by the Institute of Medicine15 and by Starfield.36,189 The table highlights the component(s) of the NCQA measure that are relevant to each domain, identifies elements that are missing in current conceptualizations and measures, and provides examples of potential additional sources of items for measuring each domain. The fact that some instruments are listed for multiple domains is an indication that these measures have some common elements and assess some of the same domains, although often in different ways.
Comparative details about these measures are discussed in the online Appendix for readers who may be choosing measures for particular circumstances. In addition, a forthcoming supplemental issue of Healthcare Policy compares the psychometrics and performance of measures of primary care constructs,190–198 and provides an excellent starting point for those seeking to measure critical aspects of primary care and the PCMH.
This overview of the definition and measurement of the patient-centered medical home leads to a number of research and policy recommendations:
The PCMH, like primary care, is worthy of support, evaluation and evolution as a fundamental building block for a high-value health care system. In these efforts, it will be important to recognize the complex interactions of the PCMH at multiple levels, so that a narrow and short-term focus does not scuttle the potentially transformative nature of the PCMH before it has had a chance to make good upon its promise.
Below is the link to the electronic supplementary material.
(DOC 402 kb)
This work was presented on July 27–28, 2009 at the Washington, DC Conference: Patient-Centered Medical Home: Setting a Policy Agenda. The authors are grateful to the Agency for Healthcare Research and Quality, the Commonwealth Fund, and the American Board of Internal Medicine Foundation for sponsoring the PCMH Evaluator’s Collaborative. We also are grateful to the Commonwealth Fund and the American Academy of Family Physicians for sponsoring our independent evaluation of the National Demonstration Project. Dr. Stange’s time is supported in part by a Clinical Research Professorship from the American Cancer Society. Critiques by the editor and reviewers were very helpful in refining the message and presentation.
Conflicts of Interest Drs. Crabtree, Jaén, Miller, Nutting and Stange are members of an independent evaluation team for the patient-centered medical home National Demonstration Project conducted by the TransforMed subsidiary of the American Academy of Family Physicians. Dr. Gill performs research consulting for GE Health Care. The authors were offered an honorarium for preparing this manuscript, but in recognition that the importance of environmental and social determinants of health199 in addition to the healthcare determinants highlighted in this paper, we asked the sponsors to donate the honorarium to: the Nature Conservancy (environment), the Rotary Foundation of Rotary International (education, poverty alleviation), and the Clinton Foundation (health security, economic empowerment, leadership development and citizen service, racial, ethnic and religious reconciliation).
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