The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care
Prepared For: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850, www.ahrq.gov
Prepared By : Deborah Peikes (Mathematica Policy Research, Inc.), Janice Genevro (Agency for Healthcare Research and Quality), Sarah Scholle (National Committee for Quality Assurance), and Phyllis Torda (National Committee for Quality Assurance). A companion white paper commissioned by AHRQ contains additional details: Scholle SH, Torda P, Peikes D, Han E, Genevro J. Engaging Patients and Families in the Medical Home. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2.) AHRQ Publication No. 10-0083-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2010. Access to these publications is available on the AHRQ Web site at http://pcmh.ahrq.gov.
National Committee for Quality Assurance, a not-for-profit organization, develops and administers a program to qualify practices as patient-centered medical homes.
Peikes D, Genevro J, Scholle SH, Torda P. The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care. AHRQ Publication No. 11-0029. Rockville, MD: Agency for Healthcare Research and Quality. February 2011.
Access to these publications is available on the AHRQ Web site at http://pcmh.ahrq.gov
Question: How can decisionmakers encourage the patient-centered medical home (PCMH) to respond to and reflectthe goals, preferences, and needs of patients and their families?
Answer: Patients’ involvement in the medical home should take place on three levels: 1) engagement in their own care, 2) quality improvement (QI) in the primary care practice, and 3) development and implementation of policy and research.
Decisionmakers can promote greater patient engagement at all three levels. Opportunities include:
- Requiring primary care practices to demonstrate active engagement of patients and families in patient care and QIactivities in order to qualify as medical homes.
- Using payment strategies to support the active engagement of patients as partners in their own care and inpractice-level QI.
- Supporting practices with technical assistance, tools, and shared resources to engage patients.
- Requiring health information technology (IT) standards to recognize and promote patient engagement.
- Requiring meaningful patient input in the design, implementation, and evaluation of medical home programs.
- Supporting additional research on the feasibility and impact of patient-engagement strategies.
The PCMH is a promising model that aims to strengthen the health care system by reorganizing the way primary care practices provide care.1,2 A medical home is supported by health IT and payment reform and rests on five pillars:3
- A patient-centered orientation toward each patient’s unique needs, culture, values, and preferences; support of the patient’s self care efforts; and involvement of the patient in care plans.
- Comprehensive, team-based care that meets the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care and is provided by a cohesive team.
- Care that is coordinated across all elements of the complex health care system and connects patients to both medical and social resources in the community.
- Superb access to care that meets patients’ needs and preferences, including care provided after hours and by e-mail and telephone.
- A systems-based approach to quality and safety that includes gathering and responding to patient experience data, a commitment to ongoing quality improvement, and practicing population health management.
Many believe the PCMH model can achieve its objectives only by fully engaging patients. However, patients are unlikely to be familiar with this model of care and may think that the PCMH is simply a primary care gatekeeper with a different name. This brief outlines how decisionmakers can promote a PCMH model that is truly patient-centered and represents a genuine departure from the way care is often provided.
Involving Patients in the Medical Home at Three Levels
Decisionmakers can support primary care practices in engaging patients and families at three levels: 1) involvement in their own care, 2) quality improvement in the primary care practice, and 3) policy and research development and implementation.
1. Involvement in the Care of Patients
Primary care practices can more actively engage patients and their families and caregivers in the management or improvement of their health in four ways:
- Communicate with patients about how the PCMH works, the role of patients and providers, and what each can expect of the other in this new model of care.
- Support patients in self-care. This support includes helping all patients reduce risk factors, as well as helping patients with chronic illnesses develop and update self-care goals and care plans.
- Partner with patients in formal and informal decisionmaking. Shared decisionmaking is a formal process in which patients review evidence-based decision aids to understand the likely outcomes of different treatment options; discuss with a health care provider what is personally important to them about the risks and benefits of different options; and then decide how to proceed, in collaboration with and actively supported by providers. Informally, providing evidence-based information, discussing the pros and cons of different options, asking about patient preferences, and collaborating in decisions can improve a variety of health care decisions.
- Improve patient safety by giving patients access to their medical records so they can detect and prevent errors, and by including patients in areas such as: safe medication use, infection control initiatives, and reporting complications or errors.
2. Involvement in Quality Improvement in the Primary Care Practice
Practices can engage patients in ongoing quality improvement efforts in a variety of ways, including soliciting regular feedback through surveys, gathering additional information on patient perspectives through the formation of patient/family advisory councils, and inviting individual patients and consumer and patient organizations to contribute to QI activities.
3. Involvement in the Development and Implementation of Policy and Research
Decisionmakers and researchers can engage patients, families, and organizations that represent them in policy and research so the design and study of the medical home reflects patient perspectives. Without the explicit inclusion of patients and families to articulate their needs and perspectives, even the best-intentioned medical home policy, design, and research may miss the mark, resulting in system- and provider-centered care rather than patient-centered care.
Involving patients in the medical home is seen by some stakeholders as intrinsically valuable and as a model of care that should be pursued regardless of whether it lowers costs or improves health outcomes. Others believe that decisions about investing in patient engagement in health care should be based on evidence of increased value.
Evidence exists regarding the benefits of engaging patients in their own care, but more research is needed to identify sustainable approaches and ways to adapt these approaches to various primary care settings. Little evidence is available regarding the effects of engaging patients in practice-level QI or in policy and research. Useful examples do exist, however, of innovators engaging patients at all three levels.
Summaries of evidence and examples of innovative approaches to patient engagement are available in the companion white paper to this brief.4
To put patients at the center of the PCMH, decisionmakers could take the following steps:
1. Require that practices demonstrate the active engagement of patients and families in patient care and quality improvement activities in order to qualify as medical homes. Some of the current qualification tools could be modified so practices would need to demonstrate that they are actively obtaining and acting on feedback from patients—such as through patient experience surveys, focus groups, or patient advisory councils—to qualify as a PCMH.
2. Use payment strategies to support the engagement of patients and families in patient care and quality improvement activities. Payment strategies can be designed to compensate and incentivize practices to engage patients as active partners in their own care (such as through payment for self-management support, shared decisionmaking processes, and care coordination) and to reward practices for implementing and maintaining processes to engage patients in practice-level QI. Engagement processes may require additional costs and may require a change in practice culture. Options for incentivizing practices to actively involve patients include additional fee-for-service payments, bundled payments, and performance bonuses (for example, for higher patient-satisfaction ratings).
3. Provide practices with technical assistance, tools, and shared resources to:
- Assess their current patient engagement policies and practices and develop improvement plans.
- Engage patients in discussing what they can expect and what might be expected of them in the PCMH.
- Assess patients’ readiness for self-care, and provide self-management support.
- Improve staff communication skills using techniques such as motivational interviewing and reflective listening.
- Support shared decisionmaking.
- Obtain and use patient feedback in QI. Decisionmakers could fund the development of survey instruments and the use of low-cost or shared data collection services.
The authorized (but not yet funded) Primary Care Extension Program offers policy mechanisms for providing primary care practices with technical assistance designed to support patient engagement. If funded, the Program would need to quickly distill best practices from providers that offer models of patient engagement and from organizations that have begun to provide technical assistance for practice transformation. The Health IT Regional Extension Centers could also reinforce the use of Health IT that supports patient engagement. The work of these two programs should also be guided by patients, families, and organizations that represent them, through their inclusion as members of policy councils or other decisionmaking bodies.
4. Establish meaningful-use and certification requirements to ensure health IT promotes patient engagement. Federal and State efforts to promote meaningful use of health IT provide important opportunities to harness its capacity to support patient engagement by keeping patients better informed of the contents of their medical records and their care plans. At the Federal and State levels, increased patient engagement is highlighted by meaningful-use measures that address such topics as provision of an after-visit summary. These efforts to use health IT need to be built with input from patients. Federal requirements under the American Recovery and Reinvestment Act for demonstrating meaningful use by individual providers in future years (2015 and beyond) can make use of ongoing experience and research to include explicit measures of patient engagement. Meaningful-use requirements will need to be updated as new health IT options emerge, such as customized health coaching tools and applications on smart phones.
5. Require substantive patient input in the design, implementation, and evaluation of medical home programs. Demonstrations provide the opportunity to develop and assess patient engagement strategies in all of the ways discussed above.
6. Support additional research on the feasibility and impact of patient-engagement strategies. The promising patient-involvement strategies described above may help put patients at the center of the medical home. However, the evidence base for patient engagement in practice-level QI and policy and research is currently limited, and more work is needed on the effectiveness and feasibility of specific approaches to engage patients in their own care. Research should focus on understanding the costs and benefits of different patient-engagement strategies, and on developing feasible and sustainable models tailored to a variety of primary care settings and patients. In addition, better measures are needed to evaluate key indicators of patient centeredness, patient safety, and shared decisionmaking. Researchers and practices need low-cost, sound methods of assessing patients’ care experiences (in particular, through surveys), and incorporating the results into practice workflow and improvement activities. Finally, research will need to evolve continually as innovations in service delivery models, payment approaches, and health IT emerge.
Deliberately putting the patient at the center of the medical home is one key to ensuring that this promising model of health care delivery meets patients’ needs and achieves its potential for improving health. Decisionmakers have abundant opportunities to promote patient involvement and to test new and innovative strategies for making health care more patient centered.
- American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of a patient-centered medical home. Mar 2007. Available at: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.dat/022107medicalhome.pdf. Accessed September 14, 2010.1
- Rittenhouse DR, Shortell SM, Fisher E. Primary care and accountable care—two essential elements of delivery-system reform. N Engl J Med 2009;361(24):2301-3.2
- Adapted from Agency for Healthcare Research and Quality’s (AHRQ’s) medical home definition. Available at: page/what-pcmh. Accessed July 24, 2010.3
- Patient-Centered Primary Care Collaborative. Proof in practice: a compilation of patient centered medical home pilot and demonstration projects. 2009. Available at: https://www.pcpcc.org/guide/proof-practice. Accessed August 5, 2010.
- Scholle SH, Torda P, Peikes D, Han E, Genevro J. Engaging Patients and Families in the Medical Home. AHRQ Publication No. 10-0083-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2010.4