Health Affairs: Medical home is far from becoming reality

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The medical home model is “at risk of becoming the latest fad in a long history of unrealistic expectations and failed health reform efforts,” authors Charles M. Kilo, MD, and John H. Wasson, MD, wrote in the May issue of Health Affairs.

Kilo, chief medical officer at Oregon Health and Science University in Portland, and Wasson, professor of community and family medicine at Dartmouth Medical School in Lebanon, N.H., examined efforts to redesign office-based medical care across a 40-year span. They divided the history of practice redesign into three overlapping phases: basic investigation, model development, and dissemination.

“The medical home movement in primary care has accelerated this dissemination phase,” the authors wrote. “Although a great deal has been learned about successful practice redesign, the success of current efforts faces many formidable challenges,” including a declining primary care workforce, unrealistic expectations and the still-undefined role of the patient.

The continuing decline in primary care practitioners will not be easily or quickly reversed, said Kilo and Wasson; however, “without adequate numbers of primary care clinicians, practice redesign will be difficult."

“Although robust primary care sits at the core of high-performing healthcare, primary care alone cannot solve healthcare’s cost and quality challenges. Successful reform must focus on substantial payment redesign, overall health system reorganization and much more,” they stated.

In addition, “much remains to be learned about critical design elements such as team-based care, full patient engagement and optimal use of electronic records. Likewise, the dynamics of effective dissemination strategies are not yet well understood and may be confounded by political and payor interests,” wrote Kilo and Wasson. “Unintended consequences of the spread of the patient-centered medical home model will need to be examined and continuously corrected if primary care is to live up to expectations."

Although meaningful engagement of patients in medical care is required to attain the best outcomes, “we still have much to learn about truly meeting patients’ needs and engaging patients meaningfully in their care,” the authors wrote.

“Critical explorations in ‘patient-centeredness’ and self-management began in the 1970s,” but in the past decade, "patient-centeredness became a key focus of practice redesign efforts, with investigators focusing on shared decision making and chronic disease self-management methods and tools, for example."

Improved patient engagement is bidirectional. The shift from clinician-driven care to collaborative patient-physician relationship–based care has continued to evolve: “The ‘medical home’ became the ‘patient-centered medical home," the authors said. “The development of the Internet has been central to this evolution, as people now routinely seek information to inform their own care. Practices seek to involve individuals more directly in managing their own health, and individuals become more knowledgeable and interact with practices in new ways."

What these new tools will be, and how primary care physicians use them to interact with patients in the future, remain uncertain. How these tools will be incorporated into care in a way that optimizes outcomes and cost-effectiveness also remains to be seen, according to the authors.

What is clear is that, after 40 years, medical practice redesign is still a work in progress, Kilo and Wasson concluded. “The role of primary care in U.S. healthcare is uncertain, as is its financial support and its ability to resurrect itself from decades of decline. Nonetheless, the practice redesign and patient-centered medical home movements constitute a new foundation for securing the future of primary care."