As patients transition from one setting and one provider to another, patients are becoming confused about what to do about their health and health care. Patients are lost between acute, ambulatory, and community care settings. A new delivery model, called the Patient Centered Medical Home, is a strategy to partner with patients to navigate the health care system based on the patient's health care goals. Key characteristics of a PCMH include:
- Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
- Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
- Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
- Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
- Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.
Patient Centered Primary Care Collaborative: is a not-for-profit membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Check out the video under Medical Home on the top right of the website to learn more about the PCMH!
Broadly, the PCMH is designed to improve health care quality. The U.S. health system targets sick care, rather than preventing disease.
One critical indicator of health care quality is patient readmission. When someone is hospitalized, we spend a great deal of time and money to fix them and then shoo them out the door. We don't follow-up very well once patients are home; hence, we create a revolving door back into the hospital.
Look at the following maps and hover over your town to see your area's readmission statistics.
The Loyola University Family Medicine Clinic:
With support from LUC faculty through the I-CARE Path grant, Loyola University Health System redesigned their ambulatory care model to incorporate IPCP in a PCMH. We believe that if someone with chronic conditions use emergency and acute care frequently, that patient may need more comprehensive, coordinated care in the community as part of their day to day life. Therefore, this model will help decrease the acute care readmission revolving door by creating better systems connecting acute care with ambulatory and community-based care.
How Does I-CARE-PATH Work At Loyola?
Some health systems are interested in applying for PCMH accreditation. The following link provides information about the accreditation process through the National Committee for Quality Assurance.
Providers need to learn specific patient centered care skills. The following provides information and links to specific PCMH skills
Motivational Interviewing: Assessment skills need to include motivational interviewing techniques, which is an interview technique that focuses on the patient’s perspective, interests, values, and concerns to stimulate an intrinsic motivation to change. The following video[1,2] provides a description of what is motivational interviewing and how to do it!
Teach back is a method of ensuring the patient understands the plan of care. Rather than the provider reviewing the plan of care, the patient summarizes the information. Learn more by watching this video on the Teach Back Method.
Preparing Patient-centered Educational Materials: The Patient Education Materials Assessment Tool (PEMAT) User’s Guide can be helpful in preparing educational materials for your patients.
Care Coordination: Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient (AHRQ).
Agencies that provide care coordination resources: The Agency for Health Research and Quality (AHRQ) has many resources for models and toolkits for Care Coordination. AHRQ provides a wealth of information related to care coordination.
- The American Academy of Ambulatory Care Nursing (AAACN) offers training in care coordination.
- The American Nurses Association published a paper, entitled Framework for Measuring Nurses' Contribution to Care Coordination
- American Association of Family Physicians (AAFP) has developed statements and resources for physicians on their website.
Care Transition Programs: Care Transition Programs are designed to smooth the transition from acute care to home. Care coordination is part of that effort, but only targets a limited time post hospital discharge (e.g., 2 month). The following provides helpful resources relate to transitional programs:
Centers for Medicare and Medicaid created a community-based care transitions program (CCTP) as part of the Affordable Care Act. The CCTP created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measurable savings to the Medicare program.
Evidence-based models of transition care: Many organizations have developed their own transition care program based on one of the following models.
1References: Miller RW, Rollnick S. (1991). Motivational interviewing: preparing people to change addictive behavior. New York, NY: The Guilford Press.
2Lussier, M. & Richard, C. (2007). The motivational interview in practice. Canadian Family Physician, 53(12), 2117–2118.