Thursday, October 28, 2010

Mr. Roger's (Medical Home) Neighborhood

My image of Pittsburgh has been one of a blue-collar, rough-and-tumble town: perogies, Heinz ketchup, steelworkers, football, and Roberto Clemente. But an exhibit in Pittsburgh's airport the other day informed me that Pittsburgh also is the home of the iconic Mr. Roger's Neighborhood, the gentle PBS show that entertained toddlers for generations. Mr. Rogers always started the show off with the following verse:

"It's a beautiful day in this neighborhood,
A beautiful day for a neighbor,
Would you be mine?
Could you be mine?

It's a neighborly day in this beautywood,
A neighborly day for a beauty,
Would you be mine?
Could you be mine?

I have always wanted to have a neighbor just like you,
I've always wanted to live in a neighborhood with you.

So let's make the most of this beautiful day,
Since we're together, we might as well say,
Would you be mine?
Could you be mine?
Won't you be my neighbor?

Won't you please,
Won't you please,
Please won't you be my neighbor?"

Fittingly, the same week that I was reminded of Mr. Roger's Neighborhood, the American College of Physicians released its "medical home neighborhood" position paper. The paper was developed by a workgroup of ACP's Council of Subspecialty Societies (CSS), which is comprised of representatives of internal medicine subspecialty societies and related organizations.

The paper proposes ways that internal medicine subspecialty practices can be recognized as Patient-Centered Medical Home Neighbors (PCMH-Ns). A specialty/subspecialty practice recognized as a PCMH-N engages in processes that:

- Ensures effective communication, coordination, and integration with PCMH practices in a bidirectional manner to provide high-quality and efficient care;

- Ensures appropriate and timely consultations and referrals that complement the aims of the PCMH practice;

- Ensures the efficient, appropriate, and effective flow of necessary patient and care information;

- Effectively guides determination of responsibility in co-management situations;

- Supports patient-centered care, enhanced care access, and high levels of care quality and safety; and

- Supports the PCMH practice as the provider of whole-person primary care to the patient and as having overall responsibility for ensuring the coordination and integration of the care provided by all involved physicians and other health care professionals.

The paper proposes a set of "aspirational principles" for developing "care coordination agreements" between the PCMH-N and the PCMH to "define the types of referral, consultation, and co-management arrangements available." ACP also proposes that incentives be aligned to support PCMH-Ns, including "some form of enhanced payment to cover the time and infrastructure costs of providing services consistent with the PCMH-N definition."

I think that the PCMH-N concept is critical to building a health care system that supports the value of primary care provided in a PCMH, but also recognizes that the model cannot work without the engagement of specialists in working together with the medical home to deliver the best care possible. It belies the notion that the PCMH is only for primary care physicians, or that ACP is uninterested in helping its subspecialist members.

If the paper's vision is realized, subspecialists should be able to give a resounding "yes" when asked by a primary care physician, "Won't you please, Won't you please, Please won't you be my neighbor?"

Today's question: What do you think of the Patient-Centered Medical Home concept as proposed by ACP's Council of Subspecialty Societies?


ryanjo said...

I like the fact that ACP is thinking ahead and setting expectations for the relationship between primary and subspecialty doctors. Of course, all this patient-centered interaction is possible right now. We're just not doing it.

The hard reality is the average internist hits the ground running from the moment s/he rolls out of bed until the last patient task is done, often late in the day. We see more patients & manage more clerical tasks (from EMR entry to filling out myriad preauths to troubleshooting our office hardware) than ever before. Given the time constraints and diverse schedules, contact between PCP and specialist, not to mention visiting nurse, physical therapist, pharmacist etc., is a rarity. Yet this is the central concept powering the PCMH.

Where is there any practical realization of this issue? The demonstration projects of PCMH seem to be academic centers or well staffed mega-groups -- no harried small practice PCPs or over-scheduled specialists coping with a 40% Medicare fee reduction. Oh, no time...we'll just tie everyone together with a modern EHR. Does anyone read the multipage nonsense that these programs produce? I challenge you to figure out what the specialist, home care nurse or physical therapist is saying between the canned, Medicare E&M-compliant prose.

Without a major restructuring of the time physicians spend on such trivia, excessive auditing and who-knows-what-else the HITECH & ACA programs dump on us, and fair payment for the effort expended, the PCMH will stay a only political buzzword and a hollow facade.

Jay Larson MD said...

I agree with ryanjo, the concept sounds good but the practicality is limited. Internists are all too busy now, and adding one more thing to do just pushes us further away from direct face to face time with patients.

Internists already have their network of subspecialists whom they use on a regular basis. These are physicians that the internist has developed confidence in that they will do the right thing for the patient. It is only when insurance companies dictate otherwise (sorry but that subspecialist that you trust is not in our network, refer to someone you don’t know). Adding one more “network” only complicates the process of referral. Maybe we can have Mark Zuckerberg, creator of Facebook whip up something to make the process of networking easier.

In regards to having a global EMR, ryanjo is correct about the jibberish notes that are saved as “encounters”. Often the medications are not “reconciled”, the note is choppy and is difficult to really understand what exactly happened and what the physician was thinking.

Since the advent of the fax machine, information can travel back and forth between offices rapidly. Perhaps this technology should be used more if information is needed.

Steve Lucas said...

There is another side to this issue, some specialist are providing primary care to their patients. For the very ill, often the doctor leading the care for the major issue will coordinate care.

At the other extreme you have the specialist who sees a patient in the normal course of care adding test to fill the primary care roll. Adding additional test to a blood draw is a simple matter.

Where we see problems is the insistence of the insurance companies, or doctors, that all of this needs to be repeated under the guidance of a front line physician: Some how repeating the process is going to improve the results.

The questions that should be asked are:

Is the patient receiving the proper test given their situation?


Is the patient happy with their care?

This is the information that should be transmitted between specialist and front line doctor.

Steve Lucas