As we embark on health care reform during the next decade, one of the challenges will be to change the delivery system from the present model. There will be less reliance on highly specialized care and more attention to primary and preventive care, with better coordination of patient care.
Based on models previously described in the pediatric literature in the 1960s, this concept of medical practice is termed the Patient- Centered Medical Home™ (PCMH). The approach emphasizes primary care that is team-based, and it manages all aspects of care across the life span, including acute, chronic, and preventive. The health care delivery system is patient- centered and increases the patient's involvement in all aspects of his or her own care; it is designed to meet personal needs and preferences. Access and communication will also improve with increased and better use of electronic media.
The medical home model will require use of evidence-based processes of care that will depend on the practice's ability to readily apply data to decision making, as well as to performance improvement. Thus, most practices will need to have electronic medical record (EMR) systems that have reasonably robust means for analyzing patient-related data.
Finally, in this model, the payment system will shift significantly from the current form of fee-forservice to perhaps global or bundled payments. A portion of any payment will be designated for care coordination, integration, and the quality of care rendered.
One should not confuse the PCMH with the old "gatekeeper" concept. The former requires a comprehensive understanding of a patient's total health care needs, significant interaction with the patient on all aspects of decision making and care, and the ability to use data effectively. The latter was often more involved with provision of primary care and referral for subspecialty care without the extensive responsibility for all aspects of care that are required of the medical home. An important question to ask is whether the ObGyn specialty can participate in the PCMH. The best answer would be, "it depends."
Practices with significant primary care orientation and experience will be able to participate, as they already provide support services for patient education and preventive measures that include nonphysician care providers who can handle noncomplex problems. They have EMR experience and know how to track patients with specific medical conditions.
If your practice is currently focused on providing traditional ObGyn care with minimal primary care, currently does not use physician extenders, and has not initiated the use of EMRs, you are probably not ready to attempt to take on the responsibility of being a PCMH.
As this concept moves forward, one of the challenges will be to devise criteria to determine how well a medical home is functioning. The National Committee for Quality Assurance (NCQA) has developed some initial standards and criteria that allow a PCHM to be recognized and evaluated (Table). The NCQA standards are heavily weighted towards information technology as opposed to other aspects of the medical home. Further, it is unclear how often and how much these standards will be modified as the PCMH concepts are tested and modified.
Although the intent of this concept is to improve quality and access and contain costs, it is still relatively untested. Only time will tell if the model, as currently conceived, will stand the ultimate test of time.
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Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19):2038-2040.