The term medical home may conjure up an image of a hospital or other type of freestanding facility, but that image is inaccurate. It isn't a physical structure at all. The medical home "facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient's family," according to a joint consensus statement released by several physician groups in March of last year. The model is receiving attention lately as a potential fix for a fragmented primary care system.
The idea was first introduced in the late 1960s. "The original concept came from the American Academy of Pediatrics [AAP], which was geared toward centralizing a child's medical and vaccination records," said Jim King, MD, president of the American Academy of Family Physicians (AAFP). "But the concept now is that everyone needs a medical home and a PCP [primary care provider] who can administer care for both acute and chronic problems. Employees of a medical home help patients navigate the health care system, ensuring that they get the services they need."
The AAFP, the AAP, the American College of Physicians, and the American Osteopathic Association, in the joint consensus statement, delineated the following requirements (among several others):
* Every patient must have a personal physician who provides the first contact and continuous, comprehensive care.
* The personal physician directs the medical practice that comprises a team responsible for ongoing patient care.
* Focus is on the whole person; the personal physician provides for or arranges appropriate care for all health care needs.
* Care is coordinated and integrated across the health care system and community.
Where are the nurses in this model? "That a paper put together by physician organizations would exclude other practitioners is not surprising," said Julie A. Stanik-Hutt, PhD, ACNP, CCNS, an associate professor at Johns Hopkins University School of Nursing and president-elect of the American College of Nurse Practitioners. In many cases NPs are "ghost" providers, she said. "Many NPs are forced to bill under physicians' names, because many insurance and health plans will not allow them to bill directly for their services."
Still, nurses will be on the front lines, with physicians providing oversight, said Jo Ann Serota, MSN, CPNP, of Ambler Pediatrics, in Ambler, Pennsylvania, who is also a representative of the National Association of Pediatric Nurse Associates and Practitioners on the AAP's Medical Home Project Advisory Committee. "When children are ready for discharge from the hospital, or if they go from the primary care office to the hospital, the hospitalists and nursing staff should work with the parents to formulate a care plan that will evolve into the primary care setting. NPs will work in collaboration with physicians in the development of this plan," Serota said.
King agrees. "One physician does not create the medical home. Everyone who is on the patient's care team is part of the medical home. That may include the pharmacist, the receptionist, the lab technician, a home health care nurse, or even nurses who care for patients in hospitals and nursing homes."
A 2006 report from the Commonwealth Fund described nurses' responsibility as one of "play[ing] central roles, working with primary care physicians to develop disease management programs for patients with chronic illness and provide support for all patients in their efforts to live healthy, productive lives."
Stanik-Hutt's concern is that these reports, being used for public policy, are too exclusionary. "The concept and its pieces are good ideas, but instead of being patient centered and including all kinds of providers, they are excluding providers other than physicians," she said. "That is not good from a policy perspective."
For example, the Centers for Medicare and Medicaid Services (CMS) is developing a medical home demonstration project in eight states in which the NP is excluded from PCP designation.
"The CMS was bound with very narrow statutory language," said Stanik-Hutt. "We spoke with them, making some recommendations on how they could implement this as part of a multidisciplinary practice. But they said there was nothing that they could do at this point."
Why should nurses get involved? The focus is the health of the whole person, reason enough for nurses to adopt the medical home concept, according to Jeanne W. McAllister, MS, MHA, BSN, codirector, Center for Medical Home Improvement in Greenfield, New Hampshire. The Pediatric Alliance for Coordinated Care, a group of six community-based pediatric practices in Boston, is a medical home for children with special needs. NPs organized and established this successful medical home in which practice-based pediatric NPs coordinate care and conduct sick visits in the home.
McAllister pointed up the opportunities for leadership roles in pediatric and adult community-based care: "Opportunities abound, but resources still have not shifted from hospitals to community-based settings," she said. "We have worked with wonderful nurses in practices, but the pipeline and workforce for the future are not there." McAllister also said that care coordination in the medical home is not on the nursing curriculum radar: "We need competencies and educational development."
Challenges to employing the medical home model. The medical home approach improves both health and cost outcomes for children and adults. The Commonwealth Fund reported in 2006 that racial disparities in health care quality and access are reduced or eliminated when patients have health insurance and a medical home. Currently, 13 states have passed legislation that encourages developing medical homes for children, and several other states have introduced bills that will expand the concept to patients of all ages.
But despite strong support, the creation of medical homes has been slow. Making a change in practice is always difficult, contends King. "Practices realize that they need to make the change, but there is always going to be some chaos involved," he said. "It's a challenge to move towards a more patient-centered practice, but providers are starting to change in that direction."
One major obstacle is reimbursement. PCPs are not reimbursed for many functions, including e-mailing patients, refilling prescriptions, and counseling new mothers about their babies, King said. "We need to have a payment system that takes that into consideration. Right now, 20% to 30% of our time is spent doing tasks for which we are not reimbursed."
Another issue is the gap between hospital salaries and a nurse's potential earnings in a primary care setting, said McAllister. She said that nurses with baccalaureates "would be an invaluable asset, but there is a huge pay gap."
Stanik-Hutt believes that NPs will become more prominent in medical homes with time. NPs may be more willing to accept Medicare and Medicaid patients when physicians are not. The number of medical school graduates going into family medicine has been declining, and the average age of family practice physicians is the late 40s and early 50s. "It is obvious that family nurse practitioners are going to have more extensive roles," she said.
Roxanne Nelson, BSN, RN