The current model of health care delivery is designed to address acute health problems
and is based on episodic face-to-face interactions between health care provider and
patient, which often do not address the needs of chronically ill individuals (1).
Diabetes is a well-documented example of a high cost prevalent chronic illness where
a significant quality chasm exists. It is one of the most expensive chronic illnesses
affecting over 23 million Americans (2) at a cost of $174 billion in 2007 (3). Despite
the high expenditures for diabetes care, very few patients with diabetes are at goal
for evidence based recommendations, with only 7% of patients at goal for A1C, blood
pressure, and LDL cholesterol (4).
In the recent years, much discussion has taken place regarding future health policies
and the need to strengthen primary care. It is believed that improvements in the mode
of delivery of primary care will better serve the needs of the chronically ill (5).
Health outcomes are better in regions in which there is an adequate supply of primary
care physicians, and patients receiving care from primary care physicians are healthier
(6) and have fewer inpatient hospitalizations (7), fewer emergent admissions (8),
a lower length of stay (8), and lower costs of care (9–11).
The Patient-Centered Medical Home (PCMH) has been proposed as a practical solution
to the primary care crisis and holds promise to deliver better chronic care. Diabetes
lends itself well to the principles of the PCMH given its robust evidence-based guidelines,
high cost, and well demonstrated quality gap. Although a common definition of the
PCMH has remained elusive (12), the basic elements of a PCMH are well described by
the Joint Principles of the American Academy of Family Medicine, American Academy
of Pediatrics, American College of Physicians and the American Osteopathic Association
(13). Those are care coordination, quality and safety, whole person orientation, personal
physician, physician leadership, enhanced access and payment (Table 1).
Table 1
Basic components of a PCMH (47)
Coordination and integration of care
Exchange of health-related information through electronic health records; use of patient
registries; care coordinator services; the physician arranges care with subspecialists
and consultants, guides the patient through the health system
Quality and safety
Decision support based on updated practice guidelines, e.g., incorporation of most
current care guidelines in daily patient flow, use of checklists and worksheets to
guarantee consistency; use of patient registries to review performance data
Whole person orientation
Comprehensive care including preventive care and end-of-life care
Personal physician
Each patient has a personal physician who is a first contact for all new health issues;
the physician knows the important psychosocial factors that may influence the health
of the patient, is culturally competent, and offers long-term comprehensive care.
Physician-directed medical practice
The physician oversees the health care team whose members communicate closely and
is a key link in coordinating their work for the optimal benefit of the individual
patient
Enhanced access
Flexible scheduling system; easy access to members of the health care team
Payment
Quality-based payment in addition to fee-for-service reimbursements of face-to-face
visits; reimbursement for care coordination; recognition of complexity and severity
of illness; sharing of savings achieved from reduced health care costs
The PCMH can be regarded as a vehicle to adopt the Chronic Care Model, a widely accepted
evidence-based guide to quality improvement efforts in the primary care setting (14).
Diabetes care has long been aligned with the key principles of both the PCMH and the
Chronic Care Model, with early recognition of the importance of patient-centered care,
self-management, patient empowerment, and team-based care as keys to better diabetes
care. One can easily imagine how these key elements described for the PCMH could be
applied to improve diabetes care. In fact, many demonstration projects include a large
focus on diabetes.
A critical component of a Medical Home practice is that members of a “well-tuned”
health care team work together through effective coordination and communication to
cultivate and promote a culture of teamwork (15,16). Information technology is an
integral part in such a working environment (17), and when combined with a commitment
to regular performance review, leads to improvements in patient-centered care including
diabetes care (18,19). An electronic health record (EHR), which stores all pertinent
patient health information, serves as a patient registry. It grants a practice the
ability to implement population-based management. Targeted data queries assist in
identifying patients who are most in need of an intervention (20). A common tactic
is identifying diabetes patients with an A1C >9.0% not seen in the last 6 months who
are then contacted and reassessed for potential care barriers (20). Health care team
meetings occur at regular intervals and include care performance measurement and improvement
as an inseparable part of the agenda. The delivery of evidence-based care is safe,
easily accessible, and affordable, with each patient having a personal physician or
provider who leads a team to ensure that care is coordinated across specialties and
providers. The team has a whole person orientation with attention to not only medical,
but also psychological and social needs. Aspects of care that do not require in-depth
medical training can be delegated to nonphysician members of the health care team
through standing orders (15). They are characterized as operating at the “top of their
license” or scope of practice (e.g., medication reconciliation, foot examinations,
vaccines, ordering of routine laboratory tests, downloading glucometer data, and telephonic
follow-up). Patients have easy access to their provider through a flexible scheduling
system and are also able to communicate with members of the health care team as needed.
These benefits of the PCMH are recognized in a reformed payment system that rewards
care coordination and quality in addition to traditional fee-for-service reimbursements
(21).
The PCMH envisions the planning of an office visit to take place well in advance of
the actual visit during which information from all sources collated (e.g., consultations
with other providers, laboratory results). This ensures a prepared proactive practice
team that can interact with the patient in a “planned visit” during which comorbidities
common in diabetes can be addressed systematically, in a timely manner, and consistently.
A care coordinator/care manager can follow up with high-risk patients between visits
to address potential barriers to adherence (15). Referral visits to subspecialty consultants,
diabetes educators, or nutritionists, can be tracked to ensure appropriate care is
received. Telephonic or secure e-mail follow-up and easy access of the health care
team can assist patients and their family members when new problems arise (15) (e.g.,
adjusting insulin dosages, medication side effects, reminders for overdue complication
screenings). Patients should have remote access from home to their own EHR (including
laboratory results) (21). Educational content pertaining to diabetes can also be accessed
via telephone or websites.
Although some traditional high-quality primary care practices may have many of the
characteristics and tools of a Medical Home already in place, active support of patient
self-management is an inseparable part of the activities of the PCMH (22). Teaching
self-management such as healthy lifestyle modification, problem solving skills, motivation,
and emotional support can be reinforced through regular follow-up by the provider.
Even though formal diabetes education has been the standard of care for diabetes,
ongoing self-management support (typically not by a physician or diabetes educator)
can be incorporated into team-based care to ensure continued patient success in achieving
self-management goals. Given the high incidence of depression in patients with diabetes,
medical homes can develop standard screening procedures for screening and treating
depression with integration of behavior health professionals into the Medical Home
team.
The PCMH movement has accelerated in recent years, driven by professional society
endorsement, National Committee for Quality Assurance (NCQA) certification, and hope
that the PCMH could empower primary care toward better quality care while reducing
costs. Nationally, efforts have already reported improvements in quality and decreased
acute care utilization and/or cost savings. These demonstrations differ from each
other in their emphasis on Medical Home elements, organization of primary care delivery,
care management, and provider reimbursement changes. Cost savings have already been
reported in at least eight Medical Home demonstrations throughout the United States
(23).
As PCMH demonstration projects are being conducted nationwide, they typically include
reimbursement changes for primary care that are either through commercial carriers,
Medicare, or Medicaid. Current demonstrations include over 14,000 providers caring
for nearly 5 million patients (24). In this review we define key elements of the PCMH
in relation to diabetes care and report demonstration pilots that include diabetes
as a target disease.
RESEARCH DESIGN AND METHODS
We collected information on Medical Home demonstrations that included quality of care
data for diabetes by performing a PubMed search using the key words “Patient-Centered
Medical Home AND Diabetes Mellitus” in the timeframe between November 1993 and April
2010. We supplemented our collection by searching for additional demonstrations with
Google, the Patient Centered Primary Care Collaborative nationwide Pilot Map (25),
the American College of Physicians PCMH website (26), and the Commonwealth Fund online
databases of Medical Home demonstrations (27). Our search focused on identifying Medical
Home demonstrations that report process and outcome measures in diabetes—either in
peer reviewed journals or formal websites. We identified 41 PCMH pilots nationwide,
11 of which were identified as reporting quality outcomes or trends in diabetes care.
We excluded three studies because of their small size (fewer than 10 practices) and
focused on identifying the interventions used to transform practices into a Medical
Home.
RESULTS
These PCMH initiatives typically include some element of payment reform (either by
a single or multiple payers) to cover infrastructure costs and care coordination.
The payer types include commercial carriers (e.g., Blue Cross, Aetna) as well as public
payers such as Medicaid. Initiatives in larger integrated health care delivery systems
also involve payers from within their own systems (e.g., Group Health Cooperative).
However, few initiatives are multipayer, making it difficult for a specific practice
to transform care for all patients because infrastructure payments are typically based
on a subset of their total patient population. Other key approaches to a Medical Home
implementation include care management, which has already been shown to be among the
most effective quality improvement strategies for glycemic control (28). Most initiatives
use patient registries to create reports of quality measures and guide quality improvement
efforts. In some initiatives practices received assistance to upgrade already pre-existing
EHRs to support registry functions while in others, practices were granted software
and technical assistance from payers. Transforming practices may be guided by regular
learning sessions during which experiences are exchanged and future steps planned.
Some initiatives have also augmented this by practice coaching. Although many initiatives
are at the early stages without published outcomes, reports of initial improvements
in diabetes care are becoming available. Eight demonstrations in particular are worthy
of further note (Table 2).
Table 2
PCMH demonstrations reporting outcomes in diabetes care
PCMH demonstration
Start
Size
Improvements
Key transformation features
Community Care of North Carolina
1998
1,200 practices; 3,000 physicians
Improvements in A1C, blood pressure, and LDL cholesterol control (29); all three measures
were above the NCQA target benchmarks. Reductions in emergency room and inpatient
admissions; reductions in outpatient and pharmacy utilization (29)
Care coordination assisted by care managers; (Medicaid) – Single payer; PMPM fee;
regular reporting of quality measures; community health networks
Geisinger Health System
2006
25 outpatient practice sites; 110 physicians
Improvements in the diabetic bundle (9 evidence-based quality indicators of diabetes
care) (19). Reduction in inpatient admissions and total medical costs (33)
Care coordination assisted by care managers; single payer; monthly payments per physician;
monthly infrastructure payments; performance-tied bonus payments; regular reporting
of quality measures; patient registry; patient access to EHR
Pennsylvania Chronic Care Initiative
2008
102 practices; 518 physicians
Improvements in A1C, blood pressure, and LDL cholesterol control in the first year
(35)
Care coordination assisted by care managers; multipayer; infrastructure payments based
on NCQA certification; regular reporting of quality measures; patient registry; practice
coaches; learning collaborative
Rhode Island Chronic Care Sustainability Initiative
2008
13 practices; 53 physicians
Improvements in A1C documentation, blood pressure control, and smoking advice documentation
6 months after begin of the initiative (36)
Care coordination assisted by care managers; multipayer; PMPM fee; care management
reimbursement; regular reporting of quality measures; patient registry; practice coaches;
learning collaborative
Group Health Cooperative Medical Home Pilot
2007
1 Seattle clinic serving 9,200 adult patients
Improvement in the composite quality score in the first and second year (38). Improved
patient satisfaction; reductions in emergency room and inpatient admissions; return
of $1.5 for every dollar invested in the PCMH after 21 months (38)
Care coordination assisted by care managers; single payer; no reimbursement change;
reduction of physician panel size; regular reporting of quality measures; patient
registry; daily care team huddles to plan day, address problems and root cause analysis
Health Partners Medical Group, Minneapolis
2002
600 physicians; 50 clinics
Improvements in A1C, blood pressure, LDL cholesterol, aspirin use and tobacco cessation
(40). Reductions in inpatient admissions and readmissions; clinic cost savings (40)
Care coordination assisted by care managers; single payer; change from salary to productivity
based physician payments; regular reporting of quality measures; patient registry;
learning collaborative
Colorado PCMH Pilot
2009
17 practices
Improvements in A1C, LDL cholesterol and blood pressure control (42); all measures
above NCQA quality benchmarks including tobacco cessation and depression screening.
Reductions in emergency room and inpatient admissions; improved patient satisfaction;
improved healthcare worker satisfaction (42)
Care coordination assisted by care managers; multiple payer; PMPM fee; pay-for-performance
payments; regular reporting of quality measures; patient registries; practice coaches;
learning collaborative
The PCMH National Demonstration Project
2006
36 practices
Improvements in chronic illness care quality (44). No improvements in patient experience;
practice coaches helpful in adopting more Medical Home features (44)
Care coordination; regular reporting of quality measures; patient registry; improved
access; practice coaches; learning collaborative
PMPM, per-member-per-month.
The Community Care of North Carolina (29,30) is considered to be one of the first
adult care PCMH initiatives. All regions of North Carolina are engaged in this Medicaid
Managed Care program involving nearly 3,000 providers and 1,200 physician practices.
Community Health Networks consisting of local practices, hospitals, and the local
Department of Health have been established. Each network provides case managers who
assist with the coordination of care for the sickest high-risk diabetic patients and
are augmented by an engaged pharmacist. Several practices often share a local case
manager with whom they have a long-term established relationship. Case managers also
have access to claims data to identify high-risk patients. Providers receive payments
in addition to the regular Medicaid fee schedule. It consists of a per-member-per-month
fee that initially started at $5.50: part paid to the provider ($2.50) and part to
the local Community Health Network to finance the case manger and pharmacist activities
($3.00) (29). Participating practices are required to regularly submit diabetes quality
indicator data to the state. These data are shared among practices and thought to
encourage competition for quality improvements. Thanks to reductions in emergency
room visits, pharmacy utilization, and both inpatient and outpatient care, annual
savings of at least $161 million have been estimated (29). Diabetes care quality measures
in 2006 exceeded the NCQA set thresholds for A1C, blood pressure control, and LDL
cholesterol (29). Performance measurement by the NCQA within the framework of the
Diabetes Physicians Recognition Program (31,32) consists of a scoring system for current
practice guideline-based performance measures in diabetes. The initiative has now
expanded to include Medicare participation (30).
The Medical Home initiative of Geisinger Health System (33), a large integrated health
delivery system in Pennsylvania, targets chronically ill Medicare individuals in need
of complex care. A nurse care coordinator (Personal Health Navigator) communicates
with the physician and other members of the health care team, “navigating” patients
and their families through the health system. Patients have remote access to their
laboratory results and EHR, and they can contact their provider via e-mail. Self-scheduling,
prescription refills, reminders about due preventive/screening interventions, and
educational materials are also available. Nine quality indicators of diabetes care
are tracked and all or none scoring is applied to identify patients receiving optimal
care. Patient report cards are used to share these key outcome measures over time.
Preliminary results for over 20,000 Medicare diabetic patients suggest improvements
in quality performance 1 year after implementation (33). Patients with an A1C <7%
increased from 32.2 to 34.8% (P < 0.001) and those with blood pressure <130/80 mmHg
also increased from 39.7 to 43.9% (P < 0.0001) (19). The percentage of patients satisfying
all nine quality indicators increased from 2.4 to 6.5% (19). Incentives consist of
monthly payments of $1,800 per physician and $5,000 per 1,000 Medicare patients for
infrastructure changes in each practice (33). Health plan savings are shared with
physicians if predefined quality benchmarks are met (33).
The Pennsylvania Chronic Care Initiative is the largest statewide multipayer medical
home initiative. It was initiated by the Pennsylvania Governor's Office for Health
Care Reform (GOHCR) (34). The GOHCR convened 17 of the major payers in Pennsylvania,
including Medicaid, to incentivize a statewide implementation of the PCMH in primary
care practices with diabetes as an initial target disease. GOHCR used its authority
to convene, facilitate, and lead the design of the Chronic Care Initiative, and by
doing so, provided the participating insurers and providers with antitrust protection.
The 3-year initiative started a phased regional implementation in May 2008 and involves
102 practices and 518 providers with a total diabetic patient population of over 56,000.
This patient population is quite diverse, consisting of a mix of rural and urban patient
populations with a high preponderance of small practices where the PCMH has traditionally
not been implemented. Health care teams attend quarterly Breakthrough Series Learning
Collaboratives in the 1st year and semiannually in the following 2 years. New steps
in the PCMH transition are planned and discussed during these learning sessions. Practice
coaches act as facilitators to practice change. Monthly quality data generated through
a diabetes registry is submitted by practices to the GOHCR. Practices without a registry
system were provided a free web-based registry. The reports contain diabetes care
measures such as A1C, blood pressure, LDL cholesterol, foot exam, and nephropathy.
Practices receive initial payments for infrastructure support to cover costs of being
away at the learning collaborative sessions and administrative expenses (e.g., NCQA-application
fees), with further payments based on NCQA tier certification (total of 3 tiers).
Practices may continue to receive payments from any other ongoing pay-for-performance
program administered by individual payers. Preliminary diabetes results from the 1st
year of the first regional rollout (Southeastern Pennsylvania) with 10,000 patients
demonstrate significant improvements in A1C, blood pressure control, LDL cholesterol,
complication screening, and appropriate medication use. More patients received statins
(57 vs. 36% at baseline, P < 0.01), ACE inhibitors, and angiotensin receptor blockers.
The percentage of patients with established self-management goals increased 20% to
nearly 70% (P < 0.01) (35). A similar smaller multipayer initiative in Rhode Island,
convened by the Rhode Island Office of the Health Insurance Commissioner, has begun
to report early improvements as well (36).
Washington's Group Health Cooperative (37,38) is a large integrated health care and
insurance system. It undertook transformation steps toward a Medical Home at one of
its clinics serving 9,200 patients staffed by salaried physicians (39). A 22% patient
panel reduction for each physician and the recruitment of additional primary care
staff enabled practice changes such as previsit chart reviews, patient contact prior
to scheduled appointments to address concerns, daily meetings of the care teams, and
regular quality reviews. Secure e-mail and telephone encounters were encouraged, and
the average patient visit increased from 20 to 30 min. Composite quality measures
for the PCMH clinic and 19 matched control clinics were reported at baseline, 12,
and 24 months later (38). A1C, LDL cholesterol, retinopathy, and nephropathy monitoring
were an integral part of the composite score and were not reported separately. The
PCMH patients’ composite quality score improved by 7.6% within a 2-year period (from
51 to 58.6%) (38). The rate of staff burn-out in the Medical Home was also better
after 1 year (10 vs. 30%, P < 0.02) (37). There were also fewer emergency department
visits (−29%, P < 0.001) and fewer hospitalizations for conditions that are treatable
in the outpatient setting (−11%, P < 0.001) (37). Although outpatient care costs were
higher for Medical Home patients (+$16 per patient per year, P < 0.05), emergency
medicine care costs were, however, significantly lower (−$54, P < 0.001) (37). By
the end of the first year, there was a full return on the health care work force and
structural investment (about $60,0000 annually) (39) at the PCMH clinic site (37).
By 21 months, for every $1 invested in the PCMH, a return of $1.5 was estimated (38).
Health Partners Medical Group of Minneapolis is another large integrated health system
with 50 clinic locations (40). Some of the key practical steps in PCMH implementation
included the adoption of the Chronic Care Model and organizing into “prepared clinical
teams,” each consisting of a physician, nurse and receptionist. An all or none “bundle”
of five diabetes quality measures (A1C, blood pressure, LDL cholesterol, aspirin use
and tobacco cessation) was used to assess changes in quality of care. There were improvements
between 2004 and 2008 from 4 to 25% of patients who met evidence based targets of
all five quality measures (40). Reductions in inpatient admissions (−24%) and readmissions
(−39%) were also evident (41). Clinic costs were 8% lower compared with average clinic
costs in Minnesota, a state in which average costs of health care are already below
the national average (41).
The Colorado PCMH Pilot (42) is led by a coalition of 7 major payers, 3 large employers,
and 17 pilot practices. Practices receive in-office coaching to facilitate the transformation
process and provide monthly registry quality reporting. Preliminary results toward
meeting of NCQA's performance standards for A1C, LDL cholesterol, and blood pressure
control are encouraging. This demonstration will be evaluated along with projects
in New York, Pennsylvania, Massachusetts, Rhode Island, Idaho, and Oregon by teams
supported by the Commonwealth Fund (27).
The National Demonstration Project (43), initiated by the American Academy of Family
Physicians began in 2006 when 36 mainly independent and nonacademic family medicine
practices were enrolled nationwide to transform toward a PCMH. The initiative randomized
practices to those wembracing transformation on their own vs. those transforming with
the assistance of practice coaches. At the end of the 2-year study, practices adopted
significantly more new components of the PCMH when using practice coaches compared
with self-directed practices (10.7 vs. 7.7 components, P = 0.005) (44). Overall, a
composite chronic illness score that included A1C, lipid levels, blood pressure, and
retinal exams improved in both groups of practices, however, paradoxically even more
so in noncoached practices (8.3 vs. 9.1%, P < 0.0001) (44). There were no differences
in patient reported experience.
Along with these key PCMH initiatives that have reported data on diabetes outcomes,
there are numerous other initiatives that include diabetes as a focus suggesting early
improvements (25–27). Many are in the process of formally reporting on their results
but the majority do not have well-developed evaluation plans (24).
CONCLUSIONS
Medical Home demonstrations that track quality measures in diabetes care are being
widely adopted nationally. Although randomized trials have yet to be performed, the
eight Medical Home initiatives reported provide encouraging “before and after” results
to support the PCMH as a viable mechanism to improve the quality and costs of diabetes
care. The transformation toward a PCMH and its implementation, however, varies among
the different demonstration projects. All typically include reimbursement enhancement
with most using care management.
Fundamental to the successful implementation of the elements of the PCMH model is
payment reform (45) because the current payment model only incentivizes face-to-face
visits. Time for care coordination must be recognized and a payment reform is necessary
to offset costs generated in the implementation and transformation process (46). Current
trends in payment methodologies for PCMH vary (24) but include standard fee for service
payments augmented by a per-member-per-month fee. This can also be further enhanced
by bonus payments tied to achieving predefined performance and/or shared savings models
(as used by Geisinger and Blue Cross of Northeastern Pennsylvania). Other initiatives
have focused on infrastructure payments early in the initiative to offset increased
costs of PCMH implementation (e.g., Pennsylvania Chronic Care Initiative). These reimbursement
changes are likely to be critical for small practices, which are more likely to lack
the resources and infrastructure needed (47).
Practice transformation often requires some facilitation and coaching. A practice
coach shared by multiple practices can serve different roles including technical assistance
(e.g., NCQA certification application, EHR adoption), facilitation/coordination of
processes (e.g., guide quality improvement meetings), and/or humanistic/cheerleading
aspects to encourage practices through the stressful phases of transformation. The
majority of current ongoing demonstrations nationwide are assisted by practice coaches
(24). Learning collaboratives are another key strategy used in 69% of PCMH nationwide
(24) (e.g., Pennsylvania Chronic Care Initiative). During these sessions practice
members explore and exchange ideas about the unique pathways of implementing changes.
Registry and EHR upgrade software can also be provided to individual practices by
participating payers or government stakeholders.
The NCQA has established a program for Medical Homes that certifies practices at three
tiers on the basis of the fulfillment of specific Medical Home criteria. This program
is used by the majority of current ongoing Medical Home demonstrations nationwide
(24). Practices are evaluated for the fulfillment of nine standards in 1) patient
access and communication, 2) patient- tracking and registry functions, 3) care management,
4) patient self-management and support, 5) electronic prescribing, 6) test tracking,
7) referral tracking, 8) dedication to regular quality review through performance
reporting and improvement, and 9) advanced electronic communication. Practices must
meet minimum criteria within these categories, five of which are required for level
1 certification. Level 2 and 3 certification is dependent on fulfilling and scoring
in all 10 “must-pass” elements (48).
While the PCMH is gaining attention and popularity, transforming practices have also
been observed to encounter challenges. The transformation toward a PCMH should not
be viewed as a simple prescheduled set of steps in practice redesign or a fulfillment
of certification requirements in stages. Instead, it represents a long lasting commitment
to transformation and adaptability to patient needs. Observations from the National
Demonstration Project found that although many practices began the demonstration with
a preexisting EHR, it has been a challenge to establish registry and patient portal
functions (49). Nationally, EHR adoption has been slower than expected (50). To facilitate
further adoption and enable communication among different providers, policy makers
have focused efforts on incentivizing and standardizing EHRs (51). Physicians’ attempting
to redirect efforts toward treating and maintaining the health of larger population
groups in addition to treating individual patients is a task requiring a change in
mindset (39,49,52). Learning sessions have proven very important in regards to reenergizing
participants for practice redesign although it seems that some have reported difficulties
transferring the motivation and enthusiasm for change to team members who did not
participate in these sessions (49). Finally, good leadership and personal transformation
on the part of a physician is needed to facilitate team work.
Only 3 years ago, pursuit of a medical home pilot required a well-informed leap of
faith. The size of that leap has grown significantly smaller based on recent reports
which have found at minimum cost neutrality and in most cases cost savings. As the
business case builds, more PCMH demonstrations are likely to blossom across the country
with many including diabetes as one of the focus illnesses. Early results for diabetes
care quality are encouraging and individual PCMH demonstrations will continue to attract
attention in the near future as they report further results.