Medical home model gains momentum

Greg Prazar, MD, a general pediatrician from Exeter, N.H., doesn't hesitate to screen for depression or attention-deficit/hyperactivity disorder, two challenging diagnoses some physicians avoid because they may not have the resources to deal with the results.

"The questions you were afraid to ask, you're not afraid any more when you know you've got support," he said.

This example is just one of the many ways adopting the "medical home" model, originally developed to coordinate care for children with significant disabilities, benefits all of his patients, according to Dr. Prazar.

His practice acts as the center of care. All medical records are managed there. A care coordinator handles referrals for a wide array of problems, even for nonmedical ones, such as transportation difficulties or issues with the child's school. He also has parent collaborators heavily invested in making his practice work better for them.

"Doing this kind of work allows you lots of wonderful opportunities to make meaningful positive changes in your practice," he said. "And you learn about complex conditions from the experts in your practice -- the parents."

Dr. Prazar is part of a trend in which more and more physicians are turning to the medical home model to improve the quality of care. The phenomenon is also getting the attention of medical societies.

In March, the American Academy of Family Physicians proposed a version of this model as the future of their specialty. More recently, the American Academy of Pediatrics hosted the July Community Access to Child Health and Medical Home National Conference in Chicago, which brought together doctors, nurses, social workers, and, for the first time, parents and patients to develop practical skills to aid them in building and strengthening the medical home concept.

"A medical home is basically where you go to receive care, where the relationship between a physician and a patient starts, and where care is coordinated," said Tim Geleske, MD, a member of the AAP's Medical Home Project Advisory Committee and a general pediatrician from Arlington Heights, Ill.

Papers presented at the AAP conference offered evidence that variations of the medical home concept could address a number of health indicators. Linking mothers and fathers of abused and neglected children to parenting education may make it less likely for them to cause harm to their offspring again. Incorporating lay health promoters during the prenatal care of low-income women made it more likely these women would return later to immunize their infants. Working with the public transportation system to provide education about available services as well as funding to pay for transportation to clinic visits seemed to make low-income minority patients less likely to miss appointments.

Many barriers exist

But while the model has an increasing number of fans, it has its opponents, too. The AAFP paper, which was published in the March/April Annals of Family Medicine, generated dozens of angry letters.

Doctors complained that while the notion was a nice idea, implementing it was fraught with difficulty. The technology for the recommended electronic centralized medical record was too expensive and lacked standardization. Letter writers also felt they lacked the funding to coordinate care and that specialists did not respect them enough to participate.

"The new model ... expects family doctors to become the leaders of multidisciplinary teams, but does not clarify how these teams will be funded," wrote Armando F. Delgado, MD, a family physician from Merritt Island, Fla. "The model also fails to clarify how that leadership role will benefit the physician and where he will find the time to coordinate all these professionals."

Even those who favor the approach admit that money is a significant issue. At the AAP meeting, some complained that their work is often hampered by insurance hassles. Patients switch doctors often because of frequent insurance changes, and doctors often stop taking certain insurance carriers for a wide array of reasons.

"It's absolutely a barrier," said Dr. Geleske. "We have people leave all the time, and we've had to leave some insurance programs because of the demands that they were putting on us."

Some physicians say, though, that hurdles such as reimbursement problems can be tackled. Jill Rinehart, MD, a pediatrician in a two-doctor practice in Burlington, Vt., convinced local insurers to pony up after studying the amount of unreimbursed time devoted to care coordination efforts.

"We put a monetary value on the work, much of it unreimbursed, that we had been doing and wanted to continue doing in order to maintain a standard of excellence," said Dr. Rinehart. "It took two or three years, but, now, whether or not we have a face-to-face encounter, [the insurance companies] will actually reimburse us for care coordination activities done each month."

And, despite the challenges, the medical home concept is needed more than ever, its supporters say. In some ways, it's an old-fashioned concept that harkens back to the days when most doctors were generalists and handled nearly all aspects of patient care. In the age when more physicians than ever are specialists, medical home advocates say the model is necessary not just to maintain the role of primary care in medicine, but also to coordinate the numerous specialists that patients, especially those with chronic conditions, need to see.

"Acute illness is becoming less and less of a major player," said Dr. Geleske. "And as medicine has become much more specialized, coordination of care is much more important. When you're seeing so many specialists, sometimes the right hand doesn't know what the left hand is doing."