Dr. Lonnie E. Fuller Jr., medical director for the Pennsylvania Medicaid ACCESS Plus
PCCM-DM Program, discusses what it takes to implement a successful advanced medical home.
The components to implementing an advanced medical home include use of technology, financial states, transformation skills and cultural change. Meeting these components can lead to quality improvement in care and improvement in the medical home itself.
After reviewing their performance on taking care of diabetics, ACCESS Plus realized that they often didn’t screen diabetics for kidney disease with a urine for microalbumin. When a staff member went to the exam room, he would usually discusse a range of topics with patients — blood sugar at 350, fungal rash, headache, depression — but would often forget to do urine for microalbumin. ACCESS Plus then set up standing orders. If a medical assistant who updated the patient’s flow chart noticed that it had been more than a year since they had the test, they would send off the urine for microalbumin. ACCESS Plus went from the fifth percentile to the 95th percentile nationwide in screening diabetics for kidney disease. This simple change took work off the physician’s hands and delivered better care.
The next component of the advanced medical home is financial support. Primary care practices are currently working as hard as they can, but still not earning as much as other doctors. Healthcare organizations need to provide financial support to cover the office staff that now has more work because they’re doing the standing orders. Funding also needs to be provided in order to implement technology. For example, if you do a disease registry, you have to pay your staff for the time required to enter the data. If you do EHRs, you must not only pay for them, but also the staff time necessary to modify the records for your use. Finally, the practices must examine how they accomplish tasks, the processes they use and the changes they need to make.
Another component of the advanced medical home is practice transformation skills. Quality improvement or process improvement is a learned skill. Quality improvement is not taught in medical schools. Family medicine residency programs are now required to document that residents have competence in systems of care. This is the first time there has been a widespread approach to process improvement on the physician level. A number of healthcare resources have said that if you made sure that all the doctors knew what needed to be done and received a continuous medical education, that that did not improve the percentage of patients who received that standard of care. In addition, if you put technology into practice, that alone would also not solve the problem.
High-performing practices invested significantly in EHRs with local adaptation. This enables you to build triggers into your EHRs that reflect your clinical priorities. Higher-performing practices are more likely to have providers who are given a brief guideline summary. This ensures that everyone is on the same page. Physicians in higher- performing practices are more receptive to guidelines.
You must have a well-planned implementation process. Everything organizations do goes through that process. If you have a quality improvement model, that’s a key piece to solving a problem.
Cultural change is the final component of the advanced medical home. Part of cultural change is whether or not your staff is comfortable pointing out mistakes or problems to the physician. Can they tell the physician when they are wrong? Will the physician let the staff determine how to do their job? Physicians are trained to not trust anyone. They are trained to be the master craftsman who interviews the patient, examines the patient, looks at all the labs, orders all the tests, comes up with the treatment plan and implements the treatment plan.
Source: Framing the Medical Home Model of Care: Blueprint from Early Adopters, April 2008
Framing the Medical Home Model of Care: Blueprint from Early Adopters
In the face of a primary care crisis, this special report chronicles the provider and payor experiences on the road to establishing medical homes for their respective populations. This 45-page resource describes the skills, technology, cultural change and financial incentives necessary to transform a physician practice into a medical home. It also presents a game plan for health plans that are ready to embrace and reimburse this model of care.
Framing the Medical Home Model of Care: Blueprint from Early Adopters is available from the Healthcare Intelligence Network for $147 by visiting our
Online Bookstore or by calling toll-free (888) 446-3530.
