EDITORIAL
Home is Where the Patient is A Ground-level Perspective on the Patient-centered Medical Home Sarah L. Cutrona, MD, MPH* and Sheri A. Keitz, MD, PhDw
I
magine a medical model that would improve satisfaction for patients, providers, and staff, save costs, and improve quality and safety outcomes. Imagine this could be implemented broadly across systems and revive our exhausted primary care networks. Too good to be true? Perhaps. But these are the hopes pinned on the Patient Centered Medical Home (PCMH). The definition of PCMH depends on who you ask. Let us start with the aerial view. The National Committee for Quality Assurance (NCQA), the body that provides broadly accepted PCMH certification, identifies 6 domains: patient-centered access, team-based care, population health management, care management and support, care coordination and transitions, and performance measurement and quality improvement. These are “concisely” described in 228 pages of 8 downloadable documents.1 The Veteran’s Affairs version of PCMH, Patient Aligned Care Teams (PACT), has 8 domains,2 whereas the AHRQ definition has 5,3 and the American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association have issued a joint statement of principles with 7 domains.4 And it goes on. A 2010 systematic review identified 29 professional, government, and academic sources offering a wide array of PCMH definitions.5 All definitions share a focus on patient-centric, coordinated care, and enhanced access. So why do we care that different organizations choose different definitions? Before drawing conclusions on the implications of a PCMH scale–based study, we need to descend to ground level. We must understand which scale was chosen, why, and whether it was reasonable to measure the association between the domains and the chosen outcomes. In this issue of Medical Care, Shi et al assess the relationship between PCMH adoption in HRSA-funded safety net health centers (HCs) and clinical performance measures.6 The authors selected the Safety Net Medical Home Scale (SNMHS), designed to capture key features of PCMH in safety-net medical homes.7 Shi et al compare results of the SNMHS total and subscale scores to HC clinical performance measures, obtained from the entire HC population (if the HC used an electronic health record that could provide such a report) or through manual data extraction on a random sample of 75 patients. Using rigorous analytic techniques, the authors found that the aggregated total PCMH score was not associated with measured outcomes. Further, there were different directional relationships in the subdomains. Strong performance in the access/communication domain was associated with improved outcomes, whereas strong performance in patient tracking/registry was associated with worse outcomes, and there was little or no effect on outcomes for the remaining 4 domains. Was SNMHS the optimal scale to use? Birnberg, the creator of the SNMHS, suggests that this scale addresses areas of particular importance to safety-net clinics.3 From the *Duke University and Durham VA Medical Center, Durham, NC; and wUniversity of Massachusetts, Worcester MA. Dr Cutrona receives grant funding from Pfizer Independent Grants for Learning & Change in an ongoing relationship and is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR000160. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr Keitz receives compensation for editorial work done for JAMA’s The Rational Clinical Examination Series but does not have any current grant, federal or industry funding. The authors declare no conflict of interest. Reprints: Sheri A. Keitz, MD, PhD, University of Massachusetts and UMass-Memorial Health System, Worcester MA 01655. E-mail: sheri.keitz@ umassmemorial.org. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/15/5305-0387
Medical Care
Volume 53, Number 5, May 2015
www.lww-medicalcare.com |
387
Medical Care
Editorial
Volume 53, Number 5, May 2015
Safety-net providers face enormous hurdles when seeking timely access to specialty services for patients with limited or no insurance coverage. Understanding whether clinic providers can arrange timely specialist care, a measure found in the SNMHS external coordination domain8 (with no direct analog in the NCQA scale), tells us about the quality of specialist care received by safety-net patients. Language services for patients with limited or no English proficiency, addressed in 4 of the 11 SNMHS access/communication domain questions, are also critical to safety-net clinics. The SNMHS emphasizes overall clinic experience, asking about bilingual clinical and nonclinical staff, in-person and phone interpretation services, eliciting greater detail than is found in the NCQA scale. The SNMHS also has a patient tracking/registry domain. For this domain, perhaps motivated by a recognition of limited resources, the scale dedicates 5 of the domain’s 7 questions to asking “how easy” it would be for clinic staff to generate registry-type information about “the majority of your patients.” In its closest analog, NCQA asks respondents whether they are able, annually, to proactively identify “populations of patients” and remind them of needed services. If we accept that unique characteristics of HCs provide compelling justification for the choice of the SNMHS, we are left to ponder why Shi et al’s results are so variable and whether this variability makes sense. We are not convinced that the external coordination domain in SNMHS should even be expected to have an association with the selected clinical outcomes. Childhood immunization and pap testing are commonly the responsibility of the primary care team, as are hypertension control and diabetes management, except in extremely difficult cases. The selected outcomes might not logically correlate with access to specialists or other components of this domain. In contrast, we can reasonably suppose that the access and communication domain, with its unique emphasis on language services, ease of scheduling, and ease of obtaining medical advice, might be associated with improved outcomes, as it was. The patient tracking/registry domain poses the greatest challenge to interpretation. Why would patient tracking/ registry have a negative correlation with outcomes? Here, the study by Shi et al may identify a data measurement or discovery effect rather than a true difference in care quality.
1. NCQA. Patient-centered medical home recognition. Available at: http:// www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed March 8, 2015. 2. Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the veterans health administration. Am J Manag Care. 2013;19: e263–e272. 3. AHRQ. Patient centered medical home resource center. Available at: http://pcmh.ahrq.gov/. Accessed March 14, 2015. 4. Joint principles of the patient-centered medical home, c2007. Available at: http://www.acponline.org/running_practice/delivery_and_payment_ models/pcmh/demonstrations/jointprinc_05_17.pdf. Accessed March 14, 2015. 5. Vest JR, Bolin JN, Miller TR, et al. Medical homes: “where you stand on definitions depends on where you sit”. Med Care Res Rev. 2010;67: 393–411. 6. Shi L, Lock DC, Lee D-C, et al. Patient-centered medical home capability and clinical performance in HRSA-supported health centers. Medical Care. 2015;53:389–395. 7. Birnberg JM, Drum ML, Huang ES, et al. Development of a safety net medical home scale for clinics. J Gen Intern Med. 2011;26:1418–1425. 8. Safety net medical home scale (SNMHS) with exact questions and scoring algorithm Commonwealth Fund, c2011. Available at: http:// www.commonwealthfund.org/B/media/files/publications/other/2011/ safety-net-medical-home-scalefinal722.pdf?la = en. Accessed March 15, 2015.
388 | www.lww-medicalcare.com
Copyright
Clinics with better systems to track all patients, whether easy or hard to find, may provide a more accurate snapshot of their population. Patients who lack disease control and those with greater barriers to care may be more readily captured. These systems may not have more patients that lack control; rather, they may be better at finding patients in trouble and thus appear to have worse performance. So, can we use the results of this article as a resounding endorsement of PCMH interventions in HCs? Probably not. Nor is this an indictment of existing PCMH initiatives. Rather, this important work by Shi et al contributes to our recognition of PCMH complexity. As clinicians, we believe one cannot simply study PCMH from afar. One cannot assume that PCMHs operate uniformly, predictably, or in isolation of their settings. Shi et al’s findings remind us to come down to ground level, step into the clinic, and take a close look at the PCMH settings we are studying. The information we gain by applying a PCMH scale must have these questions as an anchor: What aspects of PCMH influence clinical outcomes for these patients? What does PCMH mean right here? REFERENCES
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Home is Where the Patient is A Ground-level Perspective on the Patient-centered Medical Home Sarah L. Cutrona, MD, MPH* and Sheri A. Keitz, MD, PhDw
I
magine a medical model that would improve satisfaction for patients, providers, and staff, save costs, and improve quality and safety outcomes. Imagine this could be implemented broadly across systems and revive our exhausted primary care networks. Too good to be true? Perhaps. But these are the hopes pinned on the Patient Centered Medical Home (PCMH). The definition of PCMH depends on who you ask. Let us start with the aerial view. The National Committee for Quality Assurance (NCQA), the body that provides broadly accepted PCMH certification, identifies 6 domains: patient-centered access, team-based care, population health management, care management and support, care coordination and transitions, and performance measurement and quality improvement. These are “concisely” described in 228 pages of 8 downloadable documents.1 The Veteran’s Affairs version of PCMH, Patient Aligned Care Teams (PACT), has 8 domains,2 whereas the AHRQ definition has 5,3 and the American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association have issued a joint statement of principles with 7 domains.4 And it goes on. A 2010 systematic review identified 29 professional, government, and academic sources offering a wide array of PCMH definitions.5 All definitions share a focus on patient-centric, coordinated care, and enhanced access. So why do we care that different organizations choose different definitions? Before drawing conclusions on the implications of a PCMH scale–based study, we need to descend to ground level. We must understand which scale was chosen, why, and whether it was reasonable to measure the association between the domains and the chosen outcomes. In this issue of Medical Care, Shi et al assess the relationship between PCMH adoption in HRSA-funded safety net health centers (HCs) and clinical performance measures.6 The authors selected the Safety Net Medical Home Scale (SNMHS), designed to capture key features of PCMH in safety-net medical homes.7 Shi et al compare results of the SNMHS total and subscale scores to HC clinical performance measures, obtained from the entire HC population (if the HC used an electronic health record that could provide such a report) or through manual data extraction on a random sample of 75 patients. Using rigorous analytic techniques, the authors found that the aggregated total PCMH score was not associated with measured outcomes. Further, there were different directional relationships in the subdomains. Strong performance in the access/communication domain was associated with improved outcomes, whereas strong performance in patient tracking/registry was associated with worse outcomes, and there was little or no effect on outcomes for the remaining 4 domains. Was SNMHS the optimal scale to use? Birnberg, the creator of the SNMHS, suggests that this scale addresses areas of particular importance to safety-net clinics.3 From the *Duke University and Durham VA Medical Center, Durham, NC; and wUniversity of Massachusetts, Worcester MA. Dr Cutrona receives grant funding from Pfizer Independent Grants for Learning & Change in an ongoing relationship and is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR000160. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr Keitz receives compensation for editorial work done for JAMA’s The Rational Clinical Examination Series but does not have any current grant, federal or industry funding. The authors declare no conflict of interest. Reprints: Sheri A. Keitz, MD, PhD, University of Massachusetts and UMass-Memorial Health System, Worcester MA 01655. E-mail: sheri.keitz@ umassmemorial.org. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0025-7079/15/5305-0387
Medical Care
Volume 53, Number 5, May 2015
www.lww-medicalcare.com |
387
Medical Care
Editorial
Volume 53, Number 5, May 2015
Safety-net providers face enormous hurdles when seeking timely access to specialty services for patients with limited or no insurance coverage. Understanding whether clinic providers can arrange timely specialist care, a measure found in the SNMHS external coordination domain8 (with no direct analog in the NCQA scale), tells us about the quality of specialist care received by safety-net patients. Language services for patients with limited or no English proficiency, addressed in 4 of the 11 SNMHS access/communication domain questions, are also critical to safety-net clinics. The SNMHS emphasizes overall clinic experience, asking about bilingual clinical and nonclinical staff, in-person and phone interpretation services, eliciting greater detail than is found in the NCQA scale. The SNMHS also has a patient tracking/registry domain. For this domain, perhaps motivated by a recognition of limited resources, the scale dedicates 5 of the domain’s 7 questions to asking “how easy” it would be for clinic staff to generate registry-type information about “the majority of your patients.” In its closest analog, NCQA asks respondents whether they are able, annually, to proactively identify “populations of patients” and remind them of needed services. If we accept that unique characteristics of HCs provide compelling justification for the choice of the SNMHS, we are left to ponder why Shi et al’s results are so variable and whether this variability makes sense. We are not convinced that the external coordination domain in SNMHS should even be expected to have an association with the selected clinical outcomes. Childhood immunization and pap testing are commonly the responsibility of the primary care team, as are hypertension control and diabetes management, except in extremely difficult cases. The selected outcomes might not logically correlate with access to specialists or other components of this domain. In contrast, we can reasonably suppose that the access and communication domain, with its unique emphasis on language services, ease of scheduling, and ease of obtaining medical advice, might be associated with improved outcomes, as it was. The patient tracking/registry domain poses the greatest challenge to interpretation. Why would patient tracking/ registry have a negative correlation with outcomes? Here, the study by Shi et al may identify a data measurement or discovery effect rather than a true difference in care quality.
1. NCQA. Patient-centered medical home recognition. Available at: http:// www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed March 8, 2015. 2. Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the veterans health administration. Am J Manag Care. 2013;19: e263–e272. 3. AHRQ. Patient centered medical home resource center. Available at: http://pcmh.ahrq.gov/. Accessed March 14, 2015. 4. Joint principles of the patient-centered medical home, c2007. Available at: http://www.acponline.org/running_practice/delivery_and_payment_ models/pcmh/demonstrations/jointprinc_05_17.pdf. Accessed March 14, 2015. 5. Vest JR, Bolin JN, Miller TR, et al. Medical homes: “where you stand on definitions depends on where you sit”. Med Care Res Rev. 2010;67: 393–411. 6. Shi L, Lock DC, Lee D-C, et al. Patient-centered medical home capability and clinical performance in HRSA-supported health centers. Medical Care. 2015;53:389–395. 7. Birnberg JM, Drum ML, Huang ES, et al. Development of a safety net medical home scale for clinics. J Gen Intern Med. 2011;26:1418–1425. 8. Safety net medical home scale (SNMHS) with exact questions and scoring algorithm Commonwealth Fund, c2011. Available at: http:// www.commonwealthfund.org/B/media/files/publications/other/2011/ safety-net-medical-home-scalefinal722.pdf?la = en. Accessed March 15, 2015.
388 | www.lww-medicalcare.com
Copyright
Clinics with better systems to track all patients, whether easy or hard to find, may provide a more accurate snapshot of their population. Patients who lack disease control and those with greater barriers to care may be more readily captured. These systems may not have more patients that lack control; rather, they may be better at finding patients in trouble and thus appear to have worse performance. So, can we use the results of this article as a resounding endorsement of PCMH interventions in HCs? Probably not. Nor is this an indictment of existing PCMH initiatives. Rather, this important work by Shi et al contributes to our recognition of PCMH complexity. As clinicians, we believe one cannot simply study PCMH from afar. One cannot assume that PCMHs operate uniformly, predictably, or in isolation of their settings. Shi et al’s findings remind us to come down to ground level, step into the clinic, and take a close look at the PCMH settings we are studying. The information we gain by applying a PCMH scale must have these questions as an anchor: What aspects of PCMH influence clinical outcomes for these patients? What does PCMH mean right here? REFERENCES
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2015 Wolters Kluwer Health, Inc. All rights reserved.
