Featured Article
April 14, 2010
Patient Centered Medical Homes
David Thorson, M.D.Several years ago the American College of Pediatrics and the American Academy of Family Physicians developed a vision of patient care called the “The Patient Centered Medical Home” (PCMH). In 2008, the Minnesota State Legislature passed legislation to define Minnesota’s vision for a “Better State of Health.” This legislation incorporated many features of “The Patient Centered Medical Home”.
The ultimate goal is to transform medical care in three directions simultaneously.
The triple aim is to:
The triple aim is to:
• Improve the health of our patient population;
• Enhance the patient experience of care (including quality, access, and reliability); and
• Reduce, or at least control, the cost of care.
In simple terms this means that we as health care providers are being challenged to change how we provide care and how we work with patients to achieve higher value for them and ultimately improve the health of our state and nation.
There is considerable data showing that when patients are aligned with Family Physicians in a primary care setting, costs go down and the quality of care goes up (as measured by agreed on quality measures). Studies also show that when teams provide care for chronic diseases, quality goes up and costs go down.
Family Health Services Minnesota (FHSM) implemented a program that adheres to this vision over 2 years ago. The DIAMOND (Depression Initiative Across Minnesota Offering a New Direction) Project applies principles of chronic disease management to improving depression care. This program has yielded a five-fold improvement in time to remission and was featured in the Monitor (Spring 2008).
Over the next year several clinics will be piloting a model of the Medical Home that applies similar principles to diabetes and vascular disease management. They will utilize care managers, enhanced elements of electronic registries and communication and access,
as well as the formation of clinic based teams to provide care for patients. These pilots will help direct the way FHSM will integrate the principles of PCMH in our care for patients. If your clinic is involved in this pilot pleaseprovide us with feedback on how it is working for you. These changes are not easy for clinics but hopefully will provide improved outcomes as measured by quality data (reaching treatment goals), improved patient experience and improved value as measured in cost/quality index.
as well as the formation of clinic based teams to provide care for patients. These pilots will help direct the way FHSM will integrate the principles of PCMH in our care for patients. If your clinic is involved in this pilot pleaseprovide us with feedback on how it is working for you. These changes are not easy for clinics but hopefully will provide improved outcomes as measured by quality data (reaching treatment goals), improved patient experience and improved value as measured in cost/quality index.
There will be a need for patients to become more involved in their health care. We hope to accomplish this by using teams that include educators. We want to improve health not just treat disease. This means we have to identify risks early and help the patient make changes. These include lifestyle changes and improved patient choices for at risk behaviors. Health care teams cannot accomplish these goals without engaging their patients and there will be a lot of effort put into learning how best to accomplish patient engagement or activation.
At FHSM we are excited to be involved with these principles of change and look forward to working with you and your families to improve your experience as well as improving the value of your health care dollars.