Medical homes: A feasible concept?
The concept of the medical home was initially addressed more in pediatric than adult health literature. One reason for the emphasis in pediatrics was the advocacy efforts of the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners. Both groups have supported the idea that children—especially those with chronic conditions—should have a medical home. The AAP said the medical home should encompass primary care featuring seven components: It should provide continuous care and be accessible, comprehensive, family-centered, coordinated, compassionate, and culturally effective. And, the clinician providing this care should be known to the child andfamily to enhance the development of a partnership (Pediatrics. 2004;113[5 Suppl]:1545-1547).
In 2007, the AAP, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association developed a joint statement on the patient-centered medical home. The document (accessed April 7, 2009) specified that patient-centered medical homes should offer personal physicians for patients, a physician-directed medical practice, whole-person orientation, coordinated care, quality and safety, enhanced access, and an appropriate payment structure.
The importance of the medical home for adults was the focus of another 2007 issuance, this one from The Commonwealth Fund (see www.cmwf.org and search for “June 2007 Closing the Divide”).The report noted that racial and ethnic disparities in access and quality were eliminated when adults had both health insurance coverage and a medical home. Geisinger Health System reported preliminary results of a 20% reduction in hospital admissions and a 7% savings in medical costs for its medical-home model (Health Aff [Millwood]. 2008;27:1235-1245).
Is it feasible and realistic to expect each person to have access to a medical home? Proponents of the medical-home concept could cite the importance of each person's working in collaboration with a primary-care provider to enhance the overall quality of care received and to improve access to needed services. Opponents could counter that the model is unrealistic due to the complexities of the current health-care delivery system, especially when services are provided by large group practices. Patients and clinicians experience numerous barriers to care that cannot be overcome with the implementation of a medical home—for example, difficulties accessing services due to limited or no insurance coverage and the lack of available services in communities.
Despite the obstacles, preliminary evaluations by The Commonwealth Fund and Geisinger Health System have documented the success of selected medical-home models, especially when the models developed strategies to address deterrents to implementation (see www.cmwf.org and search for “Geisinger innovation in health care, Sep. 2008”). Pending final evaluation results, these models could be considered for replication in similar practice settings, including large group practices.
As members of an interdisciplinary health-care team, nurse practitioners and physician assistants can serve as key collaborators in the implementation of a successful medical home by virtue of their patient-centered expertise and their ability to communicate effectively with various disciplines to promote the coordination of needed health-care services.