The Patient-centered Medical Home Movement — Promise and Peril for Family Medicine

John C. Rogers, MD, MPH, MEd

Disclosures

J Am Board Fam Med. 2008;21(5):370-374. 

In This Article

Weaknesses

One of our weaknesses regarding the care principles is less than universal provision of desired communication skills and shared decision making, as observed by DeVoe et al in this issue of the Journal of the American Board of Family Medicine.[11] Another is that, although we may be providing continuous, team-based care that meets many patients' health needs, we do not have systems that allow us to readily document (1) that each patient has an ongoing relationship with a personal physician trained to provide first contact and continuous and comprehensive care (personal physician); (2) that a personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients (physician-directed medical practice); (3) that a personal physician is responsible for providing for all of the patient's health care needs or takes responsibility for appropriately arranging care with other qualified professionals (whole person orientation); and (4) that care is coordinated and/or integrated across all elements of the complex health care system and the patient's community.[1] Furthermore, although we believe in patient involvement in care, few of us are in practices that can boast that we use a formal care planning process between physicians and patients, that we regularly seek feedback to ensure patients' expectations are being met, and that we involve patients and families in quality improvement activities at the practice level (quality and safety principle).

These deficiencies underscore the fact that our greatest weakness is in the infrastructure principles. We have few practices that have adequate resources (capital and time) for these other elements of the care coordination and quality and safety principles:

  • registries, information technology, health information exchange;

  • evidence-based medicine and clinical decision-support tools;

  • continuous quality improvement through performance measurement and improvement;

  • information technology to support patient care, performance measurement, patient education, and enhanced communication; and

  • demonstration that the practice has the capabilities to provide patient-centered services consistent with the medical home model.

The TransforMED National Demonstration Project has identified the difficulties in changing practices to become patient-centered medical homes:

"Creating a PCMH is much more than a sum of implementing discrete model components. Such transformation is exceedingly difficult, and those who attempt it are heroic. To achieve transformation, full engagement of critical members of the practice is needed. At the same time the practice needs to remain in charge of its own destiny. They may need assistance in making the changes, but the decision what to change needs to be theirs. They also need to remain full partners in their learning and development process." [12]

 

Our weaknesses in the change process include the paucity of resources—time and money—to support practice transformation, the limited diffusion of the knowledge and skills necessary for change management, and where many of us are in the stages of change related to the PCMH (precontemplation or contemplation). Family medicine is rather weak on being able to document the care it provides, supporting the cost and effort of implementing the infrastructure elements in the PCMH principles, and supporting and managing the change process.

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