Healthy Living Messages

HealthPOWER! Prevention News - Spring 2010 (Feature Article)

The Patient Centered Medical Home Model
Richard C. Stark, MD
Director of Primary Care Clinic Operations

Jane, a 47 year old diabetic on insulin, demobilized a few months ago and attended a new patient orientation at her local Community Based Outpatient Clinic (CBOC). The clinic, pharmacy, and her benefits were explained, clinic contact information was conveyed, and Jane completed a Health Risk Assessment. After the orientation, Jane had her first visit with her Primary Care provider and was introduced to some of the other members of her Medical Home Team: her nurse care manager, clinical associate (LPN), and administrative associate. She also works with a Clinical Pharmacist and a dietitian who help her control her glucose and her weight. Jane tracks her fingerstick glucose regularly and can use My HealtheVet (MHV) to track her values. To handle most of her health needs, she can contact her Team via secure messaging right from the MHV site or she can speak to someone on the phone.

"With my busy schedule, it is difficult for me to come in for a visit, so I appreciate having access to my Primary Care Team when it's convenient for me," Jane says. "It's nice to know they are looking out for my health even when I'm not in the clinic."

More than fifteen years ago VA began a dramatic transformation from a bed-based, hospital inpatient system to one rooted in primary care. While the incorporation of Primary Care within VHA has been associated with improvements in patient satisfaction and important quality measures, our health care system still remains largely focused around the provider and health care team, rather than the patient. We are now taking our transformation to the next level by transforming all VHA Primary Care practices into Patient-Centered Medical Homes. The Patient Centered Medical Home (PCMH) Model builds upon the success of the last 15 years. It is a patient-driven, team-based approach that delivers efficient, comprehensive and continuous care through active communication and coordination of healthcare services. Implementation of a PCMH Model in all VA health care facilities takes our care to the next level and helps us deliver care in a patient centered manner, so that we can provide care that truly meets patient needs.

Patient-centered care focuses on overall health rather than the patient’s current condition or disease. A partnership among the Primary Care team, patients, their families and caregivers ensures that the patient’s wants, needs, and preferences are respected and at the hub of decision-making. Responsibility for the overall care of the patient lies with an interdisciplinary team that includes the patient and the clinical and administrative staff necessary to meet the health goals and needs of the Veteran.

Continuity is a key component of primary care, and development of a continuous, longitudinal relationship between the patient and provider is of utmost importance. The Primary Care provider directs the team in its responsibility to deliver all of the patient’s health care needs, appropriately arranging care with other qualified professionals when necessary. Communication between the patient and team members is honest, respectful, reliable and culturally sensitive. Information sharing among the team maintains a focus on the patient.

The Primary Care team uses screening, education, preventive care, lifestyle coaching, and appropriate consultation to deliver comprehensive whole-person care. The medical home team considers the community as a resource, understanding the importance of where and how people live, their exposures, experiences, and special risks that contribute to overall health. The PCMH team in partnership with the patient develops an evolving plan for care that is coordinated across all elements of the health care system. Coordination is achieved through active interdisciplinary collaboration and facilitated by registries and other information technology.

Technology is also utilized to support patient care, performance measurement, systems redesign, patient education, and enhanced communication. This allows patients to receive appropriate care when they need it, and for all team members to work at the top of their competency.

VHA began the journey to implement the medical home model in June 2009 with a summit that gathered Primary Care and other clinical experts from VHA and the private sector to discuss how VA could move forward in implementing the model. In October 2009 a PCMH readiness assessment using the American College of Physicians Medical Home Builder, an assessment and resource tool for PCMH, was administered to 850 VHA Primary Care sites. The survey indicated that VHA already has many strong PCMH practices in place. VHA is currently rolling out PCMH according to a plan which includes augmenting Primary Care Team staffing, demonstration labs that provide an opportunity to test innovations, comprehensive education for primary care teams, tactical guidance, and implementation tools.

Over the past fifteen years, VHA created arguably the best primary care system in the world. It is built on many of the key components of PCMH. However, we recognize the need to evolve and improve to better serve our patients. Redesigning our Primary Care practices as part of a process of continuous improvement aligns VA with national health care reform initiatives, enabling VA to continue to provide leadership in health care delivery while assuring that our patients’ health is managed with the utmost quality, safety and effectiveness.

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