Coordinated care: Patient-centered medical home

{"version":"0.3.0","atoms":[],"cards":[["images-card",{"images":[{"url":"http:\/\/res.cloudinary.com\/dpcbzfiye\/image\/upload\/v1459974283\/oiqdvs6ejdxbrxlcxjlv.jpg","id":"5501"}]}],["images-card",{"images":[{"url":"http:\/\/res.cloudinary.com\/dpcbzfiye\/image\/upload\/v1459974312\/lbsqvcf8jqq1jqdpvv6d.jpg","id":"5506"}]}]],"markups":[["a",["href","https:\/\/www.pcpcc.org\/about\/medical-home","target","_new"]],["a",["href","https:\/\/pcmh.ahrq.gov\/","target","_new"]],["a",["href","http:\/\/www.ncqa.org\/Programs\/Recognition\/Practices\/PatientCenteredMedicalHomePCMH.aspx","target","_new"]],["a",["href","http:\/\/www.va.gov\/health\/services\/primarycare\/pact\/index.Asp","target","_new"]],["b"],["em"]],"sections":[[1,"p",[[0,[],0,"With the advent of health reform, the evolution from a fee to a performance\nmodel, and the increasing importance of primary care, the medical home concept\nhas gained new traction. Originally introduced by the American Academy of\nPediatrics in 1967, the concept was defined as the central coordination of a\nchild\u0027s medical records. "]]],[1,"p",[[0,[],0,"Over time, the model has evolved to encompass patient- and\nfamily-centered care and population health concepts. The primary goal: to\nimprove, through better collaboration, the quality of care while reducing costs."]]],[1,"p",[[0,[],0,"Today, the patient-centered medical home (PCMH) refers to\ncoordinated primary care, with a single doctor or team that serves as the\ncentral continuity point, or home, to coordinate all aspects of a patient\u2019s\ncare. "]]],[1,"p",[[0,[],0,"Ideally, this coordination covers the entire care continuum,\nand by definition includes the patient and the patient\u2019s family as active\nparticipants in their care and wellness. Some medical home models today are\nbuilt solely around high-risk populations, such as diabetics or frequent-flyer\npatients. At its most basic, the medical home model provides a foundation for\ncoordinated, comprehensive primary care, with the outpatient clinic at the\ncenter."]]],[1,"p",[[0,[],0,"For the patient, the primary goal is to access care through\nan easily navigated, seamless workflow, a better relationship with the care\nteam, and an overall improved patient experience. A multi-disciplinary,\nco-located team allows the care to be brought to the patient, rather than the\npatient moving from space to space (waiting to vitals to lab to exam), or even\nfrom clinic to clinic. Ideally, all of the patient\u2019s health needs are\ncoordinated during the visit, no matter what brought the patient into the\nclinic. "]]],[1,"p",[[0,[],0,"A central tenant of the PCMH is to treat the whole patient\nand not just a single disease: to bring all the various medical specialties\ntogether into the care plan, if not physically. Population health and wellness\nis often a component of the medical home model, and the clinic program may also\ninclude fitness and physical therapy facilities, education centers and\ndemonstration kitchens, and in larger clinics co-located specialists such as\nophthalmologists, cardiologists, or gastroenterologists."]]],[1,"p",[[0,[],0,"Many of the best-known systems have adopted medical home\nmodels. The Cleveland Clinic has successfully employed the model in place for\nmany years. Two of the biggest health providers in the world are also adopting\nthe idea: the U.S. Department of Veterans Affairs, and the Department of\nDefense. Although they don\u2019t often use the term, Kaiser Permanente checks off\nmany of the PCMH boxes\u2014including one-stop, co-located specialties and patient\nresources, coordinated patient care, wellness initiatives, flexible scheduling\nand online physician access. In August, all of Kaiser\u2019s mid-Atlantic clinics\nearned a Patient-Centered Medical Home Level III rating by the National Committee\non Quality Assurance."]]],[1,"h3",[[0,[],0,"Lessons learned"]]],[1,"p",[[0,[],0,"While the medical home concept is more a care delivery model\nthan a physical space, it requires an integrated, team-based approach that\nalters the typical clinic layout in significant ways. Two of the biggest\nchanges involve reducing or eliminating private offices for physicians, and\ncreating a large, open teaming space, usually located at the central core, to\nfoster a higher level of communication and collaboration."]]],[10,0],[10,1],[1,"p",[[0,[],0,"The core workspace accommodates the multi-disciplinary care\nteam, which is expanded to include additional roles such as, depending on the\nstaffing model, care coordinators and nurse navigators, behavioral and social\nworkers, pharmacists, nutritionists and others working together to plan and\ndeliver holistic care to the patient. The participation and physical\nco-location of the physician as a core member of this team is a critical\ncomponent of the PCMH; hence the reduced need for physician offices."]]],[1,"p",[[0,[],0,"The open workspace and loss of office space are perhaps the\nbiggest adjustment for staff; physicians and senior staff are often quite\nreluctant to give up their individual offices. Architects can mitigate this by\nfully engaging staff in the planning and design process, and educating them on\nhow the space can be used to support and facilitate the medical home model."]]],[1,"p",[[0,[],0,"Other strategies, which\nwe\u2019ve applied from our workplace practice\u2014much of the corporate world has\nalready gone through these transitions\u2014include providing additional spaces,\nsuch as heads-down and touch-down rooms. Off-stage facilities can also help\nstaff adjust to using open workstations, including staff lounge and segregated\npatient and staff circulation."]]],[1,"p",[[0,[],0,"Visits tend to be longer in\na PCMH, and separate consulting rooms can offer a more comfortable space for\npatients to meet with providers outside of the exam room, which also\nfacilitates throughput. Added conference areas offer space for\nmulti-disciplinary caregivers to meet, as well as provide space for patient and\nfamily consults, group visits, and education. Some models incorporate an\ninitial patient intake center, usually a lounge space where the entire patient\ncare team can interview the patient and family, so that the patient only has to\ntell their history once\u2014having to repeat information over and over is a very\ncommon patient complaint. Telehealth is often a component of the PCMH model,\nbut technology is allowing this function to move into the exam and consult\nrooms rather than creating dedicated spaces."]]],[1,"p",[[0,[],0,"One of the biggest\nsurprises we have had is that, because of the increased team spaces and\nadditional space types and services (e.g., pharmacy), there is little to no\nreduction in programmed space by eliminating private offices. This is primarily\nbecause of the expanded core and the additional program space discussed above.\nFacility costs should be offset, however, by more efficient operations and\nreduced costs. Although some studies have been inconclusive, many PCMH models\nhave shown a significant reduction in emergency and hospital admissions."]]],[1,"h3",[[0,[],0,"Not a one-size-fits-all solution"]]],[1,"p",[[0,[],0,"Although the goals are\noften quite similar, implementation may differ in each institution and even\nwithin the same system. Template layouts developed for the VA\u2019s Patient Aligned\nCare Team and the Navy Medical Home Port enable differently sized clinics to\naccommodate one to three PCMH teams, depending on the patient panel size in\neach location. Modular clinical layouts for the different sized clinics follow\nspecific guidelines to encourage collaboration while improving efficiency,\nflow, and patient care."]]],[1,"p",[[0,[],0,"Some organizations may not\nbe ready to commit fully to the staffing model; others may tailor programs to\nbest suit their community. For example, the family health center template\ncreated for the MetroHealth system in Ohio\nuses a traditional clinic layout, with workstations within the clinic where\npatients can access and update their medical record, consultation rooms for\nfollow-up and care coordinators, and telemedicine capability in all exam rooms."]]],[1,"p",[[0,[],0,"Implementing the PCMH model in a new building is fairly straightforward, but adapting the concept into existing spaces can be a considerable challenge. A thorough test-fit is crucial; if the model can\u2019t be fully executed because of space deficiencies, it will hinder the staff\u2019s adoption and performance; without this, the model will likely fail. The structural bay is usually the hinge point on whether or not the necessary renovations will work. When building new, it\u2019s important to have a flexible structural bay to provide future adaptation as the model evolves."]]],[1,"p",[[0,[],0,"Ultimately, adopting the PCMH model of care rests on the staff. If providers are able to embrace this new way of working as part of an expanded team and with less personal real estate\u2014especially for physicians\u2014the PCMH can help achieve the Triple Aim: improved patient outcomes, improved patient experience, and reduced costs. Smart planning and design strategies that support the medical home model are critical to its success."]]],[1,"h3",[[0,[],0,"Helpful resources"]]],[3,"ul",[[[0,[0],1,"The Patient-Centered Primary Care Collaborative Medical Home"]],[[0,[1],1,"Agency for Healthcare Research and Quality Patient-Centered Medical Home Resource Center"]],[[0,[2],1,"National Committee for Quality Assurance Patient-Centered Medical Home Recognition Program"]],[[0,[3],1,"VA Patient Aligned Care Team"]]]],[1,"p",[[0,[4],1,"About the authors"]]],[1,"p",[[0,[5],1,"Brenna Costello, AIA,\nEDAC, and Erin McNamara, EDAC, are with SmithGroupJJR of Washington, D.C."]]],[1,"p",[[0,[],0,"\n\n\n\n \n \n\n\n\n"]]],[1,"p",[[0,[],0,"\n\n\n\n"]]],[1,"p",[[0,[],0,"\n\n\n\n"]]],[1,"p",[[0,[],0,"\n\n\n\n"]]],[1,"p",[[0,[],0,"\n\n\n\n\n"]]],[1,"p",[[0,[],0,"\n\n\n\n"]]]]}