The patient-centered medical home

Whether they are called patient-centered medical homes (PCMHs), medical homes, or anything else, they are being created to provide patients with comprehensive, integrated, efficient, and effective primary healthcare. Pharmacists, along with other healthcare professionals, are learning their roles in this still developing model of healthcare delivery.

Definitions

Definitions of a PCMH vary somewhat, but most keep the main points intact.

The National Committee for Quality Assurance states that a PCMH "is a healthcare setting that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family."

The Patient-Centered Primary Care Collaborative calls it "a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety."

According to the American College of Physicians, a PCMH should be using information technology, health information exchange, and other means to ensure that patients receive healthcare that matches their language and cultural needs, when and where they need it.

The U.S. Department of Veterans Affairs calls the team-based concept it uses at some VA facilities PACT, which stands for patient-aligned care team.

Development of an idea

The concept of a team-based primary care delivery system was first used in the late 1960s by the American Academy of Pediatrics to describe a system for keeping track of the medical care of a child in a family-centered, comprehensive, and continuous way. Since then, the concept and its definitions have been refined by the groups already mentioned, as well by as the American Academy of Family Physicians and the American Osteopathic Association.

Several organizations are dedicated to advancing the idea of medical homes, including the Patient-Centered Primary Care Collaborative. The organization has a membership of more than 1,000 medical home stakeholders and supporters, according to information posted at its website.

In some PCMH models, care may be coordinated by a physician assistant or nurse practitioner instead of a physician. In addition to these three healthcare professionals, healthcare teams can include nurses, social workers, psychologists, and pharmacists.

Growing awareness

Although the terms medical home and PCMH may be used informally to describe any comprehensive healthcare practice, there is an accrediting program run by the Accreditation Association for Ambulatory Health Care. The National Committee for Quality Assurance has created a set of voluntary standards for the recognition of medical practices as PCMHs.

"[Patient-centered medical home] is a buzzword right now. I think pharmacists know the terminology, but may not understand the requirements or the need for patient-centered medical homes," said Jean Moon, PharmD, BCACP, assistant professor in the Department of Pharmaceutical Care and Health Systems at the University of Minnesota College of Pharmacy in Minneapolis. "The pharmacists' role in this is just being discovered and being studied in the literature."

"The everyday pharmacist may not know everything about patient-centered medical homes, but they understand the overall concept," Moon said.

In addition to her academic work, Moon works part-time at Broadway Family Medicine, a PCMH in north Minneapolis. There she consults with patients, reconciles medication lists, and works to resolve medication-related issues.

Numbers TBA

The number of PCMHs in the United States is definitely growing, but it is difficult to get a handle on how many already exist, Moon said. One count conducted in Minnesota started out with about 160 PCMHs, but by the time the study was published, the list included around 200, she said. These numbers should level off as the medical practices and community health clinics that have decided to seek accreditation complete the process.

How many pharmacists are employed by PCMHs or consulting with them on a regular basis is also not known, Moon said. The ideal size and make-up of the staff in a PCMH is still being determined, she added.

"How many part-time pharmacists are needed in a certain health system? How do we optimize the time they are there?" she asked, citing areas that need more study.

PCMHs generally include pharmacists as a formal part of the healthcare team, sometimes as outside consultants, but also as full-time or part-time employees. Staff pharmacists may hold face-to-face consultations with patients who have complicated medication regimens, several coexisting conditions, or conditions that fail to stabilize or improve despite medication therapy. Other medical homes refer such patients to community pharmacists for these consultations.

MTM is key

Medication therapy management (MTM) is a key part of a PCMH, according to Hayden B. Bosworth, PhD, professor in the Department of Medicine and the Department of Psychiatry and Behavioral Sciences in the School of Medicine and School of Nursing at Duke University in Durham, N.C.

"It makes sense that the more complex the medication regimen, the more you need a pharmacist," Bosworth said. Some physicians are comfortable working on medication issues with patients who are on several prescriptions or who need complicated drug regimens, but studies have shown that teams that work with a pharmacist are more effective than those that do not, he said.

Patients who are having adherence problems also benefit from meeting with a pharmacist, he said. "We do a terrible job of recognizing medication adherence issues," Bosworth said. When increased hospitalizations and wasted medications are factored in, noncompliance to medication regimens may cost nearly $290 billion annually in the United States.

"We need to ensure - given the healthcare problems that we are facing in our society - that we figure out better ways of utilizing the role of pharmacists," Bosworth said.

Managing medications helps to keep patients out of the hospital, which is a cost-effective treatment goal of the PCMH. Medication management by a pharmacist can be more productive for those patients who need extra time and attention than they can obtain from their primary healthcare professionals.

Which patients benefit?

How to determine which patients benefit most from working directly with a pharmacist is still not well understood, Moon said. One good indicator of the need for a pharmacist consultation is the number of prescriptions the patient is filling; the more medications the patient takes, the greater the possibility for drug interactions, medication errors, side effect issues, and adherence problems, she noted. But other predictors also need to be evaluated, she said.

One strategy to determine whether patients should meet with a pharmacist is to earmark those who are taking 10 or more medications, Moon said. However, at a busy PCMH such as Broadway Family Medicine, there may be as many as 60 patients coming in each day who meet that criterion.

"There is no way that I can see 60 patients a day," she said.

A better indicator may need to be developed than simply the number of prescribed medications.

Recent hospitalizations or visits to the emergency room may be an additional useful indicator to determine which patients need a consultation with a pharmacist, she added.

Diabetes and hypertension

Many studies of MTM have centered on patients with diabetes, Moon noted. Studies have shown that patients who receive a consultation do a better job of managing their conditions and making changes in their lifestyles to help control blood glucose levels.

In a review of studies of team-model practices that looked at patients with hypertension, teams of pharmacists and nurses have been found to help patients control their blood pressure, Bosworth reported.

Reimbursement

As the PCMH model expands in numbers and scope, the issue arises of how pharmacists will be paid for their work.

Reimbursement or payment for the work of pharmacists and other professionals within a PCMH can be accomplished in several ways. One is a fee-for-service model, said Bosworth, with the pharmacist being paid for each consultation with a patient. This type of model is commonly used.

Other payment models include a care-coordination payment system and a performance-based component. The care-coordination payment covers anything that falls outside of a face-to-face visit. The performance-based component recognizes when the goal of the service has been achieved. 

All three types of payment or reimbursement models can be blended, according to the Patient-Centered Primary Care Collaborative. 

More to learn

As the healthcare system in the United States reforms and changes, PCMHs and similar practice types continue to be studied and evaluated. Research is underway and studies are being published that evaluate the effectiveness and efficiency of pharmacists and MTM within a medical home, Moon said, adding, "I think there is still a lot to learn about patient-centered medical homes."

"At end of day, the goal is to achieve coordination of care," Bosworth said. "I don't think the potential of what the pharmacist can do [within a PCMH] has been achieved."

Valerie DeBenedette is a medical news writer in Putnam, N.Y.

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Resources on the PCMH

For more information, check out these websites:

American College of Clinical Pharmacy

“The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes: Resource Guide”

Available at http://bit.ly/ACCPguide

Pennsylvania Pharmacists Association

“The Pharmacists’ Role in the Patient-Centered Medical Home”

Available at http://bit.ly/PharmRole

The American College of Physicians

Patient-Centered Medical Home page

http://bit.ly/AmColPhysPCMH

The Patient-Centered Primary Care Collaborative

http://www.pcpcc.org/

U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality
The Patient Centered Medical Home Resource Center
http://bit.ly/PCMHrc