Transforming primary care by putting the patient first

UMMS and Commonwealth Medicine advancing Patient-centered Medical Home Initiative

By Sandra Gray

UMass Medical School Communications

November 09, 2011
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Mrs. C. is a 63-year-old secretary who was recently laid off from a part-time job. A widow with three adult children, she lives alone on the third floor of an elderly housing apartment building. Her declining health since her job loss is the subject of a care team “huddle” at the office of Dr. S, her primary care physician.

Mrs. C has been generally in good shape most of her life, reports Dr. S to the group. After smoking a pack of cigarettes a day for 40 years, she quit three years ago when her husband died from lung cancer. She has gained 25 pounds since then and has a chronic cough and frequent upper respiratory tract infections. Mrs. C. was hospitalized twice in the past eight months, with the second hospitalization just three weeks ago. 

Further concerns and observations about Mrs. C are shared by the office’s medical assistant and its clinical care manager. The medical assistant has been calling Mrs. C weekly and, based on those conversations, including some about Mrs. C’s reluctance to come into the doctor’s office for fear of being admitted to the hospital, she notes that Mrs. C exhibits signs of depression.

A call to the medical assistant from Mrs. C.’s oldest daughter to discuss concerns about her mother confirms that Mrs. C doesn’t seem to be interested in the things that she formerly enjoyed. The daughter is afraid that she is not taking her medications and that she shuts off her oxygen so she can smoke.

While the news is alarming, the practice’s clinical care manager agrees that this fits with all the information the team has collected about Mrs. C’s health. The medical assistant suggests contacting the Home Health Visiting Nurse Association and Elder Services. She offers to connect Mrs. C with Community Healthlink for mental health services as well.

Mrs. C is not a real patient, but she could be. Created for training purposes, the scenario above illustrates how things might go for someone like her in a patient-centered medical home, where a primary care provider and other members of a team coordinate all of a patient's health needs, including managing chronic conditions, facilitating visits to specialists and hospital admissions, reminding patients when they need check-ups and tests and, as in this case, helping connect patients to community services that may be available to them.

In short, putting the patient first is at the heart of the patient-centered medical home. Now a centerpiece of national health care reform, the ultimate goal of the Massachusetts Patient-centered Medical Home Initiative (PCMHI) is to transform traditional primary care practices of all sizes into practices where patients, in partnership with their health care teams, achieve coordinated, comprehensive primary care that is both high quality and cost effective. 


The Patient-centered Medical Home Initiative—history in the making

Now front and center of the aspirations of federal and state legislation to improve primary care, the patient-centered medical home had its roots firmly planted long before health care reform was enacted.

First introduced by the American Association of Pediatrics (AAP) in 1967 to coordinate care for children with critical, chronic illnesses, the Joint Principles of the Patient-Centered Medical Home were mutually endorsed in 2007 by the American Academy of Family Physicians, American College of Physicians and American Osteopathic Association, along with the AAP. These guiding principles recommend that patients have personal physicians in physician-directed medical practices that apply a whole-person orientation to coordinated, integrated care. The hallmarks of these
principles include quality, safety, enhanced access and payment systems that recognize the added value of medical homes.

The Massachusetts PCMHI was established in 2009 by the Massachusetts EOHHS. In Phase I, health consulting firm Bailit Health Purchasing, LLC, convened a multi-stakeholder executive council to define and plan the initiative. The initiative is now in Phase II, in which
UMMS and CWM are leading five of its six major components, including consumer engagement, practice coaching, technology support, data aggregation and reporting, and the evaluation of the demonstration.

“The patient-centered medical home is the model of how we, as patients, want our health care delivered,” said Judith Steinberg, MD, MPH, interim chief medical officer for Commonwealth Medicine (CWM) and clinical associate professor of medicine and family medicine & community health, who is a member of the project leadership team for the Massachusetts PCMHI. She is leading the team at UMMS and CWM that is supporting the implementation of this three-year, statewide, multi-payer demonstration project. “Patients will experience improved access to care, more coordinated care, attention to quality and quality improvement, and patient-centered care, changes that will make quite an improvement over the current state of affairs.”

Representing a broad range of sizes, settings and patient populations—from large, urban community health centers to small, rural group practices—46 primary care practices were selected by the Massachusetts Executive Office of Health and Human Services (EOHHS) to participate in the Massachusetts PCMHI demonstration pilot. Sponsored by EOHHS, in partnership with Bailit Health Purchasing, LLC, and UMMS, the pilot project operates with guidance from a council and steering committee consisting of payers, providers, consumer advocates and employers. The project is also aligning with community agencies and other health care initiatives in the state.

The pilot practices are now testing new patient-centered approaches to caring for adults with diabetes and children with asthma, with the plan to expand to patients with other chronic diseases and then to all patients in the practice. Improvements will be measured in terms of patient satisfaction as well as clinical outcomes, such as how well a patient’s blood sugar levels are controlled, or the decrease in emergency room visits for asthma.

An example of how improvements could be achieved in a patient-centered medical home is by having clinical care managers routinely and proactively call patients to follow up on how they are doing at home, rather than waiting for a patient to call about a problem that might have been avoided in the first place.

The multi-faceted demonstration project involves many UMMS departments. In CWM they include Clinical Affairs, the Center for Health Policy and Research, the Massachusetts Area Health Education Centers Network, the Eunice Kennedy Shriver Center and the Office of Program Development. Other UMMS departments include the Clinical Faculty Development Center of the Department of Family Medicine & Community Health, the Departments of Pediatrics and Medicine and UMMS Information Systems.

“We developed a matrixed team from across the medical school in order to leverage our strengths. PCMHI is a cutting-edge health care reform activity, very much in keeping with our mission to improve health outcomes,” Dr. Steinberg said.

UMMS and CWM activities related to the current implementation phase of the Massachusetts PCMHI include supporting the planning and implementation of learning collaborative sessions that bring together pilot practices and community partners; developing online training tools; and recruiting and training practice coaches, called medical home facilitators, who are the on-the-ground support system for the practices participating in the pilot.

The initiative calls for each practice to assemble a PCMHI pilot team consisting of a provider champion, a day-to-day leader, a clinical/technical expert and a clinical care manager. In small practices, the team could comprise the entire practice, while in larger practices, team members fulfill the critical task of bringing the PCMHI model to the rest of their colleagues.

“We’ve developed a transformational roadmap, and have linked the learning collaborative sessions to this roadmap,” Steinberg said. “The initiative is designed so that the initial discussion about a step in the transformation roadmap begins at the learning session. Then the pilot teams go back to their practices and implement those processes during what we call the ‘action period,’ which is the period between the learning sessions. The pilot teams then return to their practices to implement those processes with the guidance and support of the medical home facilitators. In the case of Mrs. C and other patients who need coordinated care for multiple physical and mental health issues, one step in the process is establishing regular team meetings.”

“Our stepwise process helps because practices can start small, test, refine, then spread,” noted Pamela MacLeod, senior program development associate in the CWM Office of Program Development, who works behind the scenes to keep the PCMHI on track. “We’re always looking for ways to help practices.”

“Most importantly, we have participants share in their successes, their challenges and lessons learned,” Steinberg concluded.