Saturday, May 9, 2009

The Medical Home

I've been hearing a lot about the "medical home" model lately and I honestly have not been very clear on what it exactly is. It seems to have started to get more press about the time I hit my "senior slump" and stopped doing medical student rotations with much content other than leaving by noon. This video provides a good, short introduction to the concept, and Wikipedia also has a basic article.

Overall, it seems like the model has some potential to make the primary care experience better for patients and physicians alike. It was interesting to learn that the model seems to have originated out of pediatric practices caring for children with chronic illness. The experience I had in medical school that came the closest to the "medical home" model was the month I spent on outpatient pediatric heme-onc. Multiple people saw the patient and his/her at the visit: physician, infusion nurse, and social worker were key. Then others like physical therapists, speech therapists, nutritionists, other specialists were added based on the child's needs. Translators were always available, usually in person. They seemed to do such a good job of addressing everything that some parents said they felt no need to see the general pediatrician for routine visits.

So I wonder if this model could be a good way to go in the future. I have no doubt that the electronic medical record (EMR) can help dramatically in coordinating care. Having spent a good chunk of time this year at a hospital where most clinics still did paper charting, I came to see how frustrating it could be to have no way of finding out anything about a patient in a timely manner. I do not think that EMR is a magic bullet that will save the system; there are many problems with cost, implementation, and coordinating EMR across different health systems that will need to be addressed over time. But it does seem helpful at providing an accessible record for all that care for a patient within one system.

Bringing in nutritionists, PTs, psychologists might be a way to help chronically-ill patients make lifestyle changes, and could help to ease the burden on primary care physicians who do not have enough time to address these issues at routine visits. Group visits and classes could also help to shift to a more preventive focus. Kaiser offers a lot of classes for patients with chronic illness, who are going to undergo routine surgeries, for child-birth and parenting, and even preventive health classes for the "average" person. Feedback I've heard from people have attended these has been mixed, but overall positive. Of course, there is instructor variability to take into account. But Kaiser does seem to have made progress overall in reducing death from heart disease (it's in all of their ads, but if you want to know more, start on p. 20).

I'm not really sure what the medical home would mean for specialists. Would it make referrals easier? What about for hospital-based physicians? Could it improve care after discharge, which is said to often be a critical time for patients? For those of us in diagnostic specialties it seems it could help with coordinating procedures and getting results to patients in a timely manner. How helpful it is it turn around a biopsy rapidly if the patient, who is anxious and stressed that he/she may have cancer, cannot access anyone to give him/her the results?

I am sure we will hear more about the medical home in the coming months as health care reform takes center stage in Washington. It is clear that we need some drastic changes in our delivery of care in this country. Is this one of the answers? I'd be curious to hear your thoughts.


Bostonian in NY said...

They tried to do something similar to this "medical home" in my town with the local medical group. There's a single building containing my former pediatrician, my PCP and a whole bunch of specialists that take referrals from within the group (psych, cardio, ophtho, GI, etc). There aren't many surgical subs there but the list of consultants is pretty extensive. I know that there are both nutrition and social workers at the place, but PT is all external. They just started up the EMR a few years ago which made billing easier and the in-house pharmacy can have your script ready by the time you walking out the front door.

I don't think centralizing resources is going to make a huge difference in the level of care, but perhaps just the convenience. It's sort of like shopping at the supermarket vs. going to the butchers, the farmer's market and the fishmonger. I don't think the problem lies in access to resources for the majority of americans, but rather in the mindset of accessing that care. Most americans don't go to the doctor until they really need it, don't take medicine when they feel well, self-diagnose with the internet, get their health knowledge from the 5PM news, and use as much free care as they can get their hands on.

I think the major flaw in current medical system is in the concept of what "healthcare" is intended to do. The healthcare implies that it attempts to care for your health. In reality it's really just a stop-gap to keep you alive until the next major event tries to strike you down.

We (physicians) can't just wave a wand and fix most patients over the age of 55...their bodies have had years of use, abuse and neglect and just are worn out. We (physicians) need to do a better at keeping Americans well and to save them from their self-destructive behaviors, lack of control of their chronic illnesses and laziness.

It's not that I'm not hopeful that we can change our perception of how medicine, I'm just skeptical of the general population's willingness and not really comfortable with the level of paternalism necessary to enact the sort of change that we need.

The Lone Coyote said...

I completely agree that without a major change in mindset for this whole country that focuses on prevention of disease instead of popping a pill for a quick "cure," much of the reform will not be very effective for a good chunk of the population. Unfortunately, I don't think most people are ready for that conversation.