Health Care Reform’s “Medical Home”

Editor’s Corner

Raymond Carter, Editor, Medical Home News Volume 2, Number 8 August, 2010

I have invited members of the Medical Home News Advisory Board to submit short op ed pieces for inclusion in this space. Other Medical Home News readers are welcome to do so as well. This month, in fact, we feature a piece from a Medical Home News subscriber, Dr. Gerald Evans.

Medical Home Circa 1975 – Bring It Back!

By Gerald L. Evans, MD

The Medical Home Concept is trying to define itself. Is it care coordination? Is it proactive reaching out to patients instead of waiting for them to come to you? Is it physician run, nurse practitioner run, or team run? Could it be specialist run or multidisciplinary? It would appear all options are evolving as examples of the so- called medical home. I have my own bias as to what it should be, but you will figure that out below.

We have certainly seen a very definite trend in the last 20 years away from the private physician supported by a cadre of others (RNs, LPNs, Techs) to teams of health care professionals working as a team without a designated leader. Indeed, medical schools shy away from applicants known for their leadership skills in college as they preferentially want team players. Thus, in this new concept of medical home, it can be run by a physician, a nurse practitioner, or by a coordinator who is responsible for the overall patient interaction to make the parts flow amongst the providers in the group. However, before describing the medical home itself, it would be wise to define the purpose of the medical home. I find very limited descriptions of what it should actually do. Maybe it is not as implicit as the articles on the topic appear to presume. I think this will have great bearing on the structure of the successful medical home of the future.

What are the primary functions of the medical home?

#1. In my practice, I told my patients my primary responsibility was to make sure they took the best care of themselves they possibly could in order to remain free of the need for medical services and to minimize those medical needs when they did develop illnesses. Part of my initial assessment was a focus on personal behaviors, emphasizing daily aerobic exercise (all ages) and healthy low fat nutrition. Smokers were told my practice was smoke free and they had to commit to stopping smoking. I gave them 3 months to achieve that goal and told them I would bust my chops to help them. The success rate was greater than 90% and most of them quit that day. Everything I told them to do was spelled out in detail with reasons supporting its importance. Their behavioral changes were an integral part of their ongoing medical care and revisited at all visits. Laboratory work was done for baseline and to show them how effective their personal efforts were in reducing their disease risks. Avoidance of medications to treat numbers was always a goal. More detailed testing was done as clinically indicated by symptoms or risk stratification in high risk individuals — always with the thought that abnormalities were powerful reinforcement of their need to work hard in their own behalf.

The vast majority of people responded very favorably. (In addition to individual patients, I have done this with corporate, municipal, and union workers in groups at worksites with similar success and much more cost-effectively). I would add that effectiveness in this approach is enhanced by the authority of the physician. In our worksite programs, nurses, exercise physiologists, and nutritionists supported the effort, but the physician impact and leadership was a powerful motivating factor.

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Medical Home Circa 1975 – Bring It Back!…continued

#2. The second part of the medical home is patient care when needed. Preventive care is part and parcel of the above, but patients do get sick and need care. Recognition of when a patient has a significant illness is based on many factors, not the least of which is prior knowledge of the patient. The more experienced practitioner will likely be the better diagnostician. That individual can evaluate the patient quite well without involving specialists early on.

In current practice, the patient who tells his primary care physician that he has a burning discomfort deep in his anterior chest when he walks about after dinner will usually be sent promptly to a cardiologist without initial treatment or further assessment by the primary physician (risk of heart attack more concerning than acid indigestion). That will lead to a major workup starting with a stress test (likely abnormal if a typical 48 year old male with risk factors), which will lead to a cardiac catheterization and an angioplasty. In the medical home concept, that physician would have given the patient an Rx for sublingual nitroglycerin with specific instructions how to take it. The patient would also be told after testing that he should take some Tums for the next episode and then call you. The results would dictate any additional steps that may or may not be indicated.

With Steps #1 and #2 you are well on your way to a medical home concept as I see it. Obviously scheduling next steps in the computerized calendar to make sure you call the patient (smokers in particular) or the patient calls you back (results of nitroglycerin/antacid trial) should be part of any good practice. Personally, I always found email extremely useful, especially with patients who traveled a great deal. (Monitoring pro-times all over the world for Coumadin patients was easy via email.) The more medically experienced the practitioner, the less likely the patient will need referral to a specialist and the more likely they will respond to behavioral changes; i.e. the more successful the medical home.

Gerald L. Evans, M.D. is the former chief of cardiology at MetroWest Medical Center in Framingham, MA and the Founder and Director of HeartVentures, LLC in Framingham. He may be reached at evans@heartventures.com. He also maintains a blog at http://blog.heartventures.com.

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