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      Defining and Measuring the Patient-Centered Medical Home


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          The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare.

          The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care.

          The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change.

          Measuring the PCMH involves the following:
          • Giving primacy to the core tenets of primary care

          • Assessing practice and system changes that are hypothesized to provide added value

          • Assessing development of practices’ core processes and adaptive reserve

          • Assessing integration with more functional healthcare system and community resources

          • Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects

          • Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings.

          Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s11606-010-1291-3) contains supplementary material, which is available to authorized users.

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          Most cited references 161

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          Organizing care for patients with chronic illness.

          Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
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            Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

            The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.
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              Pay-for-performance programs in family practices in the United Kingdom.

              In 2004, after a series of national initiatives associated with marked improvements in the quality of care, the National Health Service of the United Kingdom introduced a pay-for-performance contract for family practitioners. This contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience. We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England in the first year of the pay-for-performance program (April 2004 through March 2005), data from the U.K. Census, and data on characteristics of individual family practices. We examined the proportion of patients deemed eligible for a clinical quality indicator for whom the indicator was met (reported achievement) and the proportion of the total number of patients with a medical condition for whom a quality indicator was met (population achievement), and we used multiple regression analysis to determine the extent to which practices achieved high scores by classifying patients as ineligible for quality indicators (exception reporting). The median reported achievement in the first year of the new contract was 83.4 percent (interquartile range, 78.2 to 87.0 percent). Sociodemographic characteristics of the patients (age and socioeconomic features) and practices (size of practice, number of patients per practitioner, age of practitioner, and whether the practitioner was medically educated in the United Kingdom) had moderate but significant effects on performance. Exception reporting by practices was not extensive (median rate, 6 percent), but it was the strongest predictor of achievement: a 1 percent increase in the rate of exception reporting was associated with a 0.31 percent increase in reported achievement. Exception reporting was high in a small number of practices: 1 percent of practices excluded more than 15 percent of patients. English family practices attained high levels of achievement in the first year of the new pay-for-performance contract. A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income. Copyright 2006 Massachusetts Medical Society.

                Author and article information

                +1-216-3686297 , +1-216-3684348 , kcs@case.edu
                J Gen Intern Med
                Journal of General Internal Medicine
                Springer-Verlag (New York )
                14 May 2010
                14 May 2010
                June 2010
                : 25
                : 6
                : 601-612
                [1 ]Family Medicine, Epidemiology & Biostatistics, Sociology and Oncology, Case Western Reserve University, 10900 Euclid Ave, LC 7136, Cleveland, OH 44106 USA
                [2 ]Case Comprehensive Cancer Center, Case Western Reserve University, 10900 Euclid Ave, LC 7136, Cleveland, OH USA
                [3 ]University of Colorado Health Sciences Center, Denver, CO USA
                [4 ]Center for Research Strategies, Denver, CO USA
                [5 ]Leonard Parker Pool Chair of Family Medicine, Allentown, PA USA
                [6 ]Lehigh Valley Health Network, Penn State College of Medicine, Allentown, PA USA
                [7 ]Family & Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
                [8 ]Epidemiology & Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, TX USA
                [9 ]Department of Family Medicine, Robert Wood Johnson Medical School, Somerset, NJ USA
                [10 ]Program Leader in Population Sciences, Cancer Institute of New Jersey, Somerset, NJ USA
                [11 ]Department of Family Medicine, Epidemiology & Biostatistics and Oncology, Case Western Reserve University, Cleveland, OH USA
                [12 ]Delaware Valley Outcomes Research, Newark, DE USA
                [13 ]Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA USA
                © The Author(s) 2010
                Original Article
                Custom metadata
                © Society of General Internal Medicine 2010

                Internal medicine

                patient-centered medical home, primary care, quality improvement, measurement


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