By Sandra Newman, MPH

The Patient Centered Medical Home (PCMH) is one of the latest buzz words being used in the media, the halls of Congress, and by many physicians. But what is the PCMH? When did it start and what does it mean for family medicine?

The underpinnings of the PCMH began in 1967, when the American Academy of Pediatrics (AAP) introduced the Medical Home as a way to help coordinate the care of special needs children. AAP published Standards of Child Health Care which defined a Medical Home as one central source of a child's pediatric records. The authors contended that, "for children with chronic diseases or disabling conditions, the lack of a complete record and a ‘Medical Home' is a major deterrent to adequate health supervision. Wherever the child is cared for, the question should be, ‘Where is the child's Medical Home?' and any pertinent information should be transmitted to that place."¹

In 2004, the American Academy of Family Physicians (AAFP) released the Future of Family Medicine report which called for every American to have a "personal Medical Home." AAFP's Medical Home would serve as the focal point through which all individuals receive acute, chronic and preventive care. Through an ongoing relationship with a family physician, patients could be assured of care that is accessible, accountable, comprehensive, integrated, Patient Centered, safe, scientifically valid, and satisfying to both patients and their physician.

The American College of Physicians (ACP), in a comprehensive 2006 report, also expressed support for the model, though they used the term "advanced Medical Home." This served as the foundation for joint principles endorsed by the AAFP, ACP, AAP, and the American Osteopathic Association a year later. These principles - focused on care coordination, whole-person orientation, and a physician-directed medical practice - have also been endorsed by the American Medical Association and a number of specialty societies, including the American College of Cardiology, the American Academy of Neurology, the American Society of Clinical Oncology, and the Society for General Internal Medicine.

So, Where Are We Now?

AAFP has joined a nationwide effort to advance the Medical Home concept, as one of the leading members of the Patient Centered Primary Care Collaborative (PCPCC). This coalition represents 50 million American workers and 330,000 doctors who advocate for primary-care-based health system reform. Purchasers, such as IBM, Boeing, and Wal-Mart, are also members. Having such a broad-based coalition is particularly useful since purchasers may have leverage related to health plan contracts and services that providers and patients do not. The Coalition's goals include working to stimulate additional Medical Home pilots by large, self-insured employers and legislation at the state and federal level. Several states are conducting Medical Home pilot projects, which include enhanced physician payment to account for increased service coordination and other activities. CAFP is in strong support of a payment system, whether permanent or through pilots, that adequately and appropriately recognizes all the coordination and teamwork that goes into patient care, and is not represented solely by time spent in the clinical encounter.

How Does the PCMH Affect Specialists?

ACP's Council of Subspecialty Societies addresses the role of specialists in the PCMH in several ways. First, the Council expressed that the PCMH should have systems to effectively communicate with both specialists and subspecialists and have efficient referral processes. They also encourage specialists to recognize and support the important role of the PCMH in coordinating care and tracking patient information and data. The Council outlines several cases in which a specialist may serve as a patient's PCMH, for example, if a patient with diabetes is on a complex insulin regime and is being cared for in an endocrinology practice or an infectious disease physician serves as the PCMH for an HIV-positive patient. But the Council further describes the role of a PCMH principal care physician as follows:

• A principal care physician with appropriate training in primary care and after discussion with the current primary care physician and patient, directly provides for the routine first contact, whole person care of the patient.
• A principal care physician with appropriate training in primary care and after discussion with the current primary care physician and patient, hires a nurse practitioner to provide for the routine first contact, whole person care of the patient.
• A principal care physician working in a multi-specialists practice recognized as a PCMH can team-up with a primary care colleague to provide the necessary routine first contact, whole person care of the patient.

What Does this Mean for Me?

In 2008, the National Committee on Quality Assurance (NCQA) developed a Medical Home certification tool known as Physician Practice Connections - Patient Centered Medical Home, or PPC-PCMH (http://www.ncqa.org/tabid/631/default.aspx). While the program is widely touted, as of January 2009, NCQA has received approximately 120 applications for the designation program.

The scoring is complicated, but basically offers certification in one of three levels and addresses the following nine standards:

• Access and communication;
• Patient tracking and registry functions;
• Care management;
• Patient self-management support;
• Electronic prescribing;
• Test tracking;
• Referral tracking;
• Performance reporting and improvement; and
• Advanced electronic communications

For a Level I designation, a practice needs to have a practice management system; Level II requires an EHR or e-prescribing; Level III would be based on interoperable technology that allows a practice to both send and receive data.

The certification process comes at a price. Practices pay NCQA $80 to use an assessment tool that helps them determine their readiness for applying for the PPC-PCMH designation. Then, the application fee is $450 per physician for a practice of up to six physicians. Despite these costs, at this time very few, if any, bonus payments are available to California physicians who receive the designation.

Beyond NCQA, there may not be any near-term opportunities to formally engage in PCMH work. But that does not mean there aren't activities each family physician can consider. AAFP's TransforMED has created a free Medical Home assessment known as MHIQ (http://www.transformed.com/MHIQ/welcome.cfm). After answering 12 questions, you can have a better sense of where your practice stands and receive recommendations that directly relate to your score. There are also a number of ways that practices can get ready for what appears to be a fait accompli. Consider what elements of the Medical Home may overlap with any pay-for-performance programs you participate in. By working on those measures, you may realize bonus payments not directly tied to Medical Home. In addition, CAFP, AAFP and others offer a number of tools that will help you consider changes in your practice. These range from enhancing the way your team works together through huddles and team meetings, to improving referral relationships for hard-to-get information, such as ophthalmology reports.

While we've heard positive feedback about the growing acceptance of recognizing family physicians' roles as care coordinators - and resulting increased pay - the Medical Home has not been without controversy. Most significantly, we've heard from some family physicians who say that they already provide a Medical Home. While that is likely true for some PCMH elements, the information in Table 1, taken from the School of Community Medicine in Tulsa, OK, is very useful in analyzing what formal efforts practices have in place. This means not just the good intentions and great work of your practice, but the appropriate systems, data, infrastructure, community supports, referral relationships, and data to know exactly where your practice stands. And of course, we look forward to a payment system that will catch up with what we already know to be true: family physicians are - and will continue to be - the best opportunity for patients to have a Medical Home.

Sandra Newman, MPH is CAFP's Director of Health Policy.

¹American Academy of Pediatrics, Council on Pediatric Practice. Pediatric Records and a "Medical Home." In: Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967: 77-79