The Medical Home - Will It Work In Peoria?

January 2009 will mark my return to clinical practice. It will be distinctly different from my previous years of practicing family medicine. I will be a solo independent physician practicing in a completely different operational and financial model.

I will become one of a growing number of primary care physicians (especially family practitioners) who "desire to regain direction of their practices, drive redesign to optimize efficiency, deliver superb care, ensure fair compensation for work, and also lower the total cost of healthcare. The ‘Ideal Medical Practice' (IMP) can move us closer to this goal" (L. Gordon Moore, MD).

An IMP model is designed to facilitate physician/patient valued interaction, reduce non-clinically relevant workloads, markedly reduce practice overhead expenses, and measure service and quality outcomes.

The IMP model is consistent with many healthcare redesign recommendations referenced in the two landmark Institute of Medicine reports, the American Academy of Family Practice "New Model of Care," and the NCQA defined Primary Care Medical Home (PCMH).

The seven principles of a PCMH are outlined below along with comments specific to my new practice which address how some of these principles will be implemented.

1. Personal Physician

I am the sole physician in the practice (no mid-level providers). I will provide first contact, continuous and comprehensive care for all patients who commit to my practice. Limiting my practice to 600-750 patients will allow this very personalized level of care.

2. Physician Directed Medical Practice

I will direct a small team (1.5 additional FTEs) who will collectively take responsibility for the ongoing care of our patient population.

3. Whole Person Orientation

I will directly provide, or directly coordinate with other selected healthcare professionals (i.e. Hospitalists), the wellness, preventive, chronic, and acute healthcare needs of my patients. The care will extend along the life cycle continuum.

4. Care is Coordinated and/or Integrated

Information technology, workflow processes, and an activated patient panel facilitate exchange of information and clinical care coordination across multiple levels of the healthcare system. Lacking full integration or interoperability between different community utilized IT systems may hinder, but should not impede the timely sharing of clinical information via electronic mechanisms.

5. Quality and Safety

Deemed the hallmark of a PCMH, the electronic health record assists with the delivery of evidenced based clinical care, decision support, and outcome measurements. In the IMP model, continuous quality improvement and the rapid cycle change (sometimes immediate) occurs because the physician and team members are always "in the loop." Feedback is continuous and immediate. If the physician/team alters the process, the effects will be observable or measurable by the next patient visit, the next review of operational or performance data, or the next patient self reporting survey results.

6. Enhanced Access

Same day access is accomplished via open scheduling, offering extended hours, and providing other options for communication between the patient, physician and staff. Access to health information must be uncoupled from the exclusive domain of the traditional office visit.

7. Payment

Current contractual fee schedules are locked into narrowly defined fee-for-service/face-to-face reimbursement models. Value added (improved outcomes, care management, greater patient satisfaction and access, healthcare cost reductions) and resource investments (IT or registry function, report writing) are not recognized by most payors.

N. Michael Jongerius, M.D.
02/01/2009