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Appendix D
The Medical Home
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TABLE D-1 The Major Differences Between the Current State of Chronic Care Management and a Future-State Medical Home Model
Current State
Future State
Primary provider
Primary care physician
Primary care clinician with health coaches
Primary incentive
Visits (volume)
Increased patient adherence to self-care regimen
Infrastructure investments
None
Electronic medical record with registry function and knowledge management tools, and personal health records for patients; required infrastructure investments in practice operations that support coaching platforms, including patient classroom facilities, websites with blog and social networking capabilities, and redesigned educational materials reflecting customized selfcare regimen for discrete patient groups (total onetime investment costs of approximately $80,000 to $120,000)
Incremental costs
None
$100,000–$115,000 per primary care clinician, $78,000 per health coach; 56 percent loada for coaching tools (data collection, telephones, information technology [IT] systems, etc.); 33 percent full-time equivalent data manager at $65,000 per data manager; and $5,000–$20,000 for health IT and website technical support annual maintenance
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Current State
Future State
Panel size
5,000–7,000 charts (1,500–2,500 active patient records)
1,000–2,000 patients, depending on prevalence and intensity of chronic care management requirements (does not include case-managed population)
Net revenues (annual, per physician)
$350,000–$600,000b
$500,000–$1 million ($500/patient in panel) inclusive of performance bonus
aInternal Deloitte references.
bCleverley and Cameron (2007).
SOURCE: Deloitte Center for Health Solutions (2008). Reprinted, with permission, from The Medical Home: Disruptive Innovation for a New Primary Care Model, http://www.deloitte.com/us/medicalhome and http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf. Copyright 2008 by the Deloitte Center for Health Solutions, part of Deloitte LLP.
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BOX D-1
Critical Features of the Medical Home: A Platform for Guided Self-Care Management
Personal physician: Each patient has an ongoing relationship with a Primary Care Physician, as well as clinician health coaches, who are trained to provide first-contact, continuous, and comprehensive care. These clinicians are competent in the use of active listening, health coaching, evidence-based holistic medicine, clinical information technology, population-based outcome improvement and measurement, care team recruitment, and leadership.
Physician-directed primary care professional organization: A physician leads a team of health coaches who collectively take responsibility for the ongoing care of patients. The day-to-day operation of the practice is focused on managing population-based outcomes and maximizing individual patient adherence to a distinct, customized self-care management program that leverages information technology. Note: A health coach is an allied professional (nurse/patient educator) with specialized training in patient behavior modification and motivational interviewing to match patient values, preferences, and triggers to specific, measurable, short-term, self-care lifestyle modifications.
“Whole person” orientation toward adherence, not compliance, incorporating holistic methods with conventional allopathic interventions: The primary care team is responsible for providing all of the patient’s health care needs and appropriately arranging care with other qualified professionals. This includes care for all stages of life: acute care, chronic care, preventive services, and end-of-life care, with strong consideration for the individual’s value system, personal preferences, and level of engagement in decision making. A key focus is the dispensation of directives (prompts, alerts, reminders) in teachable moments to patients and family members/significant influencers to expedite adherence to self-care suggestions (not just compliance to directives). In these clinical models, holistic therapeutic interventions, such as mindful daily practices, are integrated with traditional therapeutic interventions.
Monitored, coordinated and, integrated care using electronic medical records and personal health records: Care is facilitated across all elements of the complex health system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) by registries, health information exchanges, and other electronic means to ensure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner. The information exchanges among members of the patient’s care team are synchronized and real-time. These technologies are also used to reduce unnecessary visits, tests, and referrals. Sharing information among medical homes and other providers in the local and regional care system is indicative of an advanced medical home model.
Measured and managed adherence to evidence-based practices by the care team and the patient: Results measured are hallmarks of the medical home. They range from measures of processes and outcomes to patient satisfaction and success rates in changing behavior:
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Evidence-based medicine and clinical decision-support tools guide decision making. Nonadherence by the care team and/or the patient is monitored and measured, and root-cause analysis is conducted to assess errors and near-misses.
Physicians in the practice accept accountability for continuous quality improvement by voluntarily engaging in performance measurement and improvement.
Patients actively participate in decision making, and feedback is sought to ensure patients’ expectations are being met.
Information technology is used to appropriately support optimal patient care, performance measurement, patient education, and enhanced communication.
Patients and families participate in quality improvement activities at the practice level.
Enhanced accessibility: Care anywhere, anytime: Care is available via open scheduling, expanded hours, and new communications options among patients, their personal physician, and practice staff. Innovations such as group visits, cybervisits, robust customized educational tools, and self-monitoring devices are available through the practice.
Emphasis on physician incentives for improvements in self-care management: Physician reimbursements appropriately recognize the added value provided to patients who have a patient-centered medical home. The payment structure should:
Reflect the value of patient-centered care management work that falls outside of the face-to-face visit.
Pay for services associated with care coordination within a given practice and among consultants, ancillary providers, and community resources.
Support adoption and use of health information technology for quality improvement.
Support enhanced communication access such as secure e-mail and telephone consultation.
Recognize the value of technology-based physician work associated with remote monitoring of clinical data.
Allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in reduced payments for faceto-face visits.)
Recognize case-mix differences in the patient population being treated within the practice.
Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
Allow additional payments for achieving measurable and continuous quality improvements.
SOURCE: Deloitte Center for Health Solutions (2008). Reprinted, with permission, from The Medical Home: Disruptive Innovation for a New Primary Care Model, http://www.deloitte.com/us/medicalhome and http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf. Copyright 2008 by the Deloitte Center for Health Solutions, part of Deloitte LLP.
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