Can Medical Homes Live Up to Their Lofty Expectations?

Last month, the Boston Globe reported that many lawmakers on Capitol Hill—who were "intent on containing the nation's spiraling health costs" while drafting healthcare reform legislation—were promoting the "medical home" approach to providing quality healthcare. So, has its time finally come—or not?

A patient-centered medical home could be viewed as a place to attach all types of healthcare concerns. In speaking to a forum sponsored by the Alliance for Health Reform and Commonwealth Fund last fall, Robert Berenson, a senior fellow at the Urban Institute of Washington, said that policymakers seem to be hanging on the medical home idea "everything that they want to improve the health system."

That could mean many good things, Berenson said: "Better attention to diagnosing, treating alcoholism and depression, or doing shared decision-making—being more attentive to health disparities." But it could also mean that "soon you start hanging everything on this model and it dies of its own weight."

It appears he may have been on to something. In a report out this month from the Annals of Family Medicine, researchers with a two-year American Academy of Family Physicians demonstration project, said their early analysis "raises concerns that current demonstration designs seriously underestimate the magnitude and timeframe for the required changes, overestimate the readiness and expectations of information technology, and are seriously undercapitalized."

They said they feared that with current assumptions, many demonstrations going on across the country may "place participating practices at substantial risk" that may jeopardize the evolution of patient-centered medical homes. These unrealistic expectations "may set up demonstrations and evaluations for failure."

Overall, change is hard enough, the researchers said. "Transformation to a patient-centered medical home requires epic whole-practice reimagination and redesign."

But there is hope. The AAFP demonstration shows that it is possible to transform a primary care practice into a patient-centered medical home that encourages partnerships with the patients.

To make it a go, they suggest:

• Understanding that transforming a primary care practice into a patient-centered medical home requires "wholesale practice redesign" and continuous commitment to "enhancing the patient experience."
• Realizing that transformation will likely include a variety of interdependent components, such as new scheduling arrangements, better coordination with other parts of the healthcare system, more point-of-care services, and development of team-based care, among others.
• Developing and implementing an information technology infrastructure to support this transformation could be more difficult and time-consuming than may be initially anticipated. Information technology is currently underdeveloped to meet the needs of the patient-centered medical home, they said.
• Realizing that transformation involves a shift from physician-centered care to a team approach—in which patient care is shared among office staff. In addition, rapid transformation could result in staff burnout, turnover, and financial distress.
• Moving toward the patient-centered medical home model is a developmental process that can take up to five years to achieve. Those that successfully transform are highly dependent on local conditions that affect healthcare practices and their surrounding healthcare system.

In the headlong rush for widespread implementation of patient-centered medical homes, "it will be important to continue to learn from the change process and how it evolves," the researchers said. So, in the natural scheme of things, it will take a little time until we will be able to call medical homes our home sweet home.