Clinical Care - Access to Care - Adopt alternate models of care

Medical homes

Health Factors:	Quality of Care
Decision Makers:	Government - State, Healthcare Organizations
Evidence Rating:	Scientifically Supported
Population Reach:	100% of WI's population
Impact on Disparities:	Likely to decrease disparities

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Description

Medical homes provide continuous, comprehensive, whole person primary care (NCQA-PCMH, PCPCC-PCMH). In this model of care, personal physicians and their teams coordinate care across the health care system, working with patients to address all their preventive, acute, and chronic health care needs, and arranging care with other qualified health professionals as needed. Medical homes offer enhanced access, including expanded hours and easy communication options for patients. They also practice evidence-based medicine, measure performance, and strive to improve care quality (PCPCC-Joint principles).

Expected Beneficial Outcomes

Improved quality of care
Decreased preventable hospitalizations and emergency room visits
Improved chronic condition care
Decreased disparities in health care
Decreased overall cost of care

Evidence of Effectiveness

There is strong evidence that medical homes improve health care quality (Rosenthal 2008, Homer 2008, van Walraven 2010, AHRQ-PCMH). Additional evidence is needed to determine which practices yield strongest effects (AHRQ-PCMH).

Medical homes increase continuity of care (van Walraven 2010), evidence-based care (Homer 2008), and patient or family participation (Rosenthal 2008, Homer 2008). By proactively monitoring and caring for patients, medical homes can reduce preventable hospitalizations and emergency room visits (van Walraven 2010, Diedhiou 2010, Roby 2010).

Effects appear strongest for children with special health care needs (Homer 2008) and persons with chronic conditions such as diabetes or depression (Amiel 2011). Medical homes can reduce emergency visits for asthmatics (Chin 2009, Diedhiou 2010). They may also reduce disparities in health outcomes (Starfield 2004). Some medical homes have been shown to improve access and preventive care (CWF-Beal 2007), increase continuity of care, and reduce emergency room visits for low income persons (Roby 2010).

Research on primary care transformation indicates that practices becoming medical homes should first build a relationship-centered workplace with shared leadership and time for group planning. Then, rather than incremental change or following top-down orders to change, practices should pursue group-directed, whole-system transformation (Crabtree 2011, Nutting 2009). Practices should also help doctors develop the skills for team-based care, and expect a change process up to three years long (Nutting 2009).

Medical homes can yield cost savings over traditional care in some circumstances (Homer 2008, Rosenthal 2008). Most state medical home initiatives have been associated with higher quality and lower costs (Takach 2011).

Implementation Examples

United States

Medical homes have been gaining momentum nationally through institutional recommendations, the National Committee for Quality Assurance's medical home standards, and numerous demonstration projects (Amiel 2011, Nutting 2009, NCQA-PCMH eligibility). The Affordable Care Act includes some Medicare and Medicaid payment reforms consistent with medical home care (SNMHI-Health reform and the PCMH), and a medical home demonstration project involving up to 195,000 Medicare patients (US DHHS-ACA). The Safety Net Medical Home Initiative, currently underway, is intended to demonstrate a replicable, sustainable implementation model for medical home transformation (SNMHI).

Implementation Resources

AHRQ-PCMH - Agency for Healthcare Research and Quality (AHRQ). Patient centered medical home (PCMH) resource center. Accessed on June 19, 2012
Webpage: http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Tools & Resources_v2

CMHI - Center for Medical Home Improvement (CMHI). What is a medical home? Accessed on June 20, 2012
Webpage: http://www.medicalhomeimprovement.org/

National Center for Medical Home Implementation - National Center for Medical Home Implementation. How to implement - Getting started. Accessed on June 20, 2012
Webpage: http://www.medicalhomeinfo.org/

Citations - Description

NCQA-PCMH - National Committee for Quality Assurance (NCQA). Patient-centered medical home. Accessed on March 23, 2013
Webpage: http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx

PCPCC-Joint principles - Patient-Centered Primary Care Collaborative (PCPCC). Joint principles of the patient-centered medical home. Accessed on March 23, 2013
Webpage: http://www.pcpcc.net/joint-principles

PCPCC-PCMH - Patient-Centered Primary Care Collaborative (PCPCC). What is a medical home? Accessed on March 23, 2013
Webpage: http://www.pcpcc.net/what-we-do

Citations - Evidence

Amiel 2011* - Amiel JM, Pincus HA. The medical home model: New opportunities for psychiatric services in the United States. Current Opinion in Psychiatry. 2011;24(6):562-8.
Accessed on June 19, 2012
Webpage: http://journals.lww.com/co-psychiatry/Abstract/2011/11000/The_medical_home_model___new_opportunities_for.18.aspx

Chin 2009 - Chin MH, Alexander-Young M, Burnet DL. Health care quality-improvement approaches to reducing child health disparities. Pediatrics. 2009;124(Suppl 3):S224-36.
Accessed on June 19, 2012
Webpage: http://pediatrics.aappublications.org/content/124/Supplement_3/S224.full.pdf+html

Crabtree 2011* - Crabtree BF, Nutting PA, Miller WL, et al. Primary care practice transformation is hard work: Insights from a 15-year developmental program of research. Medical Care. 2011;49(12 Suppl 1):S28-35.
Accessed on June 19, 2012
Webpage: http://journals.lww.com/lww-medicalcare/Abstract/2011/12001/Primary_Care_Practice_Transformation_is_Hard_Work_.7.aspx

CWF-Beal 2007 - Beal AC, Doty MM, Hernandez SE, Shea KK. Closing the divide: How medical homes promote equity in health care. Washington, DC: The Commonwealth Fund (CWF); 2007:62.
Accessed on June 20, 2012
Webpage: http://www.commonwealthfund.org/usr_doc/1035_Beal_closing_divide_medical_homes.pdf

Diedhiou 2010* - Diedhiou A, Probst JC, Hardin JW, Martin AB, Xirasagar S. Relationship between presence of a reported medical home and emergency department use among children with asthma. Medical Care Research and Review. 2010;67(4):450-75.
Accessed on June 19, 2012
Webpage: http://mcr.sagepub.com/content/67/4/450

Homer 2008 - Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics. 2008;122(4):e922-37. Accessed on June 19, 2012
Webpage: http://pediatrics.aappublications.org/content/122/4/e922.full.pdf+html

Nutting 2009 - Nutting PA, Miller WL, Crabtree BF, et al. Initial lessons from the First National Demonstration Project on practice transformation to a patient-centered medical home. Annals of Family Medicine. 2009;7(3):254-60. Accessed on June 19, 2012
Webpage: http://www.annfammed.org/content/7/3/254.full.pdf+html

Roby 2010* - Roby DH, Pourat N, Pirritano MJ, et al. Impact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system. Medical Care Research and Review. 2010;67(4):412-30.
Accessed on June 19, 2012
Webpage: http://mcr.sagepub.com/content/67/4/412

Rosenthal 2008 - Rosenthal TC. The medical home: Growing evidence to support a new approach to primary care. Journal of the American Board of Family Medicine. 2008;21(5):427-40.
Accessed on June 20, 2012
Webpage: http://www.jabfm.org/content/21/5/427.full.pdf

Starfield 2004* - Starfield B, Shi L. The medical home, access to care, and insurance: A review of evidence. Pediatrics. 2004;113(Suppl 4):1493-98. Accessed on June 19, 2012
Webpage: http://pediatrics.aappublications.org/content/113/Supplement_4/1493.full.pdf

Takach 2011* - Takach M. Reinventing medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs. 2011;30(7):1325-34.
Accessed on June 20, 2012
Webpage: http://www.commonwealthfund.org/Publications/In-the-Literature/2011/Jul/Reinventing-Medicaid.aspx

van Walraven 2010* - van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: A systematic and critical review. Journal of Evaluation in Clinical Practice. 2010;16(5):947-56.
Accessed on June 19, 2012
Webpage: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2009.01235.x/abstract

Citations - Implementation Examples

NCQA-PCMH eligibility - National Committee for Quality Assurance (NCQA). Eligibility for PCMH recognition. Accessed on June 20, 2012
Webpage: http://www.ncqa.org/tabid/1472/Default.aspx

SNMHI - Safety Net Medical Home Initiative (SNMHI). Patient-centered care for the safety net. Accessed on June 23, 2012
Webpage: http://www.safetynetmedicalhome.org/safety-net/about.cfm

SNMHI-Health reform and the PCMH - Safety Net Medical Home Initiative (SNMHI). Health reform and the patient-centered medical home: Policy provisions and expectations of the patient protection and affordable care act. Accessed on July 2, 2012
Webpage: http://www.safetynetmedicalhome.org/payment-policy/healthcare-reform

US DHHS-ACA - US Department of Health & Human Services (US DHHS). New Affordable Care Act (ACA) support to improve care coordination for nearly 200,000 people with Medicare. Accessed on June 20, 2012
Webpage: http://www.hhs.gov/news/press/2011pres/06/20110606a.html

* Journal subscription may be required for access.

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Evidence Rating

Level of effectiveness based on a scan of academic literature and key recommendations of leading organizations.

Scientifically Supported Numerous studies or systematic review(s) with positive results
Some Evidence Research suggests positive impacts; further study may be warranted
Expert Opinion Recommended by credible groups*; research evidence limited
Insufficient Evidence Evidence limited or unavailable; further study warranted
Mixed Evidence Evidence mixed; further study warranted
Evidence of Ineffectiveness Research consistently shows program is detrimental or has no effect

Although many policies and programs are recommended by credible groups, we apply the rating ‘expert opinion’ only when policies are recommended but limited scientific evidence of effectiveness is available.

* The American Heritage Dictionary defines credible as 'capable of being believed; plausible.' and 'worthy of confidence; reliable.' To be considered an 'expert recommendation,' policies and programs must be recommended by one or more organizations that are recognized for their impartial expertise in the area of interest and have limited evidence available.

Potential Population Reach

Portion of Wisconsin's population likely to be reached by a policy or program if implemented statewide, based on its characteristics (e.g., target population(s), geographic limitations, and potential implementers).

	<1%			20-49%
	1-9%			50-99%
	10-19%			100%

Potential Population Reach

	<1%			20-49%
	1-9%			50-99%
	10-19%			100%

Potential Impact on Health Disparities

Likely impact of a given policy or program on racial/ethnic, socioeconomic, geographic or other disparities in Wisconsin based on its characteristics (e.g., target audience, mode of delivery, etc.) and best available evidence related to disparities.

Likely to decrease disparities
No impact on disparities likely
Likely to increase disparities