Important Points Made by the Speakers
- Financial, cultural, or linguistic barriers can result in health care that is fragmented and uncoordinated. (Wong)
- The patient-centered medical home—a relationship with a health care provider and health care team that knows a person’s health issues and is accountable for taking care of that person—offers multiple opportunities to advance health equity. (Bau)
- Performance standards for patient-centered medical homes can drive quality improvements, but feedback needs to be immediate and continual. (Bau)
- Many people tend not to see issues around diversity, disparities, and equity to be a concern, and the complexity of the ACA has detracted from the necessary discussion around diversity. (Andrulis)
In introducing the session on patient-centered medical homes, Winston Wong, director of disparities improvement and quality initiatives at Kaiser Permanente, recounted the story of Mr. Kwong (not his actual name), whom Wong met in the community clinic where he sees patients. Mr. Kwong was a recent immigrant from China who was struggling with hypertension, arthritis, and other problems. After a period when Mr. Kwong was not seen at the clinic, Wong learned that he had suffered an acute psychotic break. “I was
haunted by the fact that, as a primary care physician, I had not known that he had been hospitalized in such a situation,” Wong recalled. Mr. Kwong did not know English, and the institution into which he was placed probably did not know his linguistic issues, family situation, or cultural competency issues. “What could I have done for Mr. Kwong?” Wong asked. “How could we have made Mr. Kwong’s experience one that we would have said that we could be proud of?”
Mr. Kwong’s situation happens repeatedly in the U.S. health care system, Wong continued. Because of financial, cultural, or linguistic barriers, the care that patients receive may be fragmented and uncoordinated. Furthermore, the social determinants of health may compound those barriers. For someone like Mr. Kwong, who lived in a single-room residence hall with few support services or points of contact with other people, coordination is a great challenge.
Caring for such patients will require a multifaceted approach, explained Wong, including
- Supporting and coordinating care across the care delivery experience;
- Addressing cultural, linguistic, social, and financial factors that affect clinical outcomes;
- Involving multidisciplinary health care teams across the continuum of care; and
- Supporting institutions so that they provide the best possible care to their patients.
Two other speakers at the workshop explored these and other aspects of patient-centered medical homes. Both emphasized the promise of the ACA to promote racial and ethnic equity as well as the many practical difficulties that must be overcome to realize this promise.
“How could we have made Mr. Kwong’s experience one that we would have said that we could be proud of?”
The term “patient-centered medical home” may not be the best name for the concept, said Ignatius Bau, who has been a consultant to many different groups on how to meet the needs of vulnerable populations. It is too narrow because it refers to a place more than to a relationship. A patient-centered medical home is essentially a relationship with a health
care provider and health care team that knows a person’s health issues and is accountable for taking care of that person.
Patient-centered medical homes offer multiple opportunities to advance health equity. For example, community health centers could improve their quality outcomes and their competitiveness in today’s health care market by becoming patient-centered medical homes. The Health Resources and Services Administration and Centers for Medicare & Medicaid Services (CMS) are helping community health centers make the transition. At 500 sites around the country, federally qualified health centers are taking part in demonstrations of Advanced Primary Care Practice, which are designed to result in the development of patient-centered medical homes. Similarly, many public hospitals with ambulatory clinics are moving in this direction. Such hospitals often function like community health centers in the neighborhoods where they operate, said Bau. “Their challenge is to say they’re not just a walk-in place where you can go when you have no place else to go, but you can come to the hospital clinic’s medical home where you have a consistent provider who knows who you are and what your needs are,” he explained.
Individual and small medical practices can also serve as medical homes. Bau pointed to data from the 2010 National Ambulatory Medical Care Survey that reported that most office visits occur in physicians’ offices, rather than community health centers or hospital clinics. Furthermore, many of these offices are small, with just one or two providers. A study with which Bau was involved—conducted by the California Medical Association Foundation and looking at racial and ethnic minority doctors in California—found that these physicians are in fact part of the safety net but are not recognized as such (Maas et al., 2008). They accept Medicaid, Medicare, and uninsured patients or do not charge their patients. A similar study of Asian American physicians (Bau and Tran, 2012) reported similar findings, said Bau. These practices, too, need to be included in the movement toward medical homes, and organizations such as the National Committee for Quality Assurance (NCQA, 2009) and the Center for Health Care Strategies (CHCS, 2010) are providing support for this transition.
The National Committee for Quality Assurance (NCQA) has established six standards for patient-centered medical homes, and Bau discussed how each could affect health disparities.
Providing access to continuous care requires culturally and linguistically appropriate services, which entails assessing the racial and ethnic diversity of one’s patients, assessing the linguistic needs of one’s patients, providing interpretation or bilingual services to meet those needs, and providing printed materials in the appropriate languages. For practice teams, this standard
includes training and assigning care teams to support patients and families in self-management, self-efficacy, and behavior change; training and assigning care teams for patient population management; and training team members in communication skills and designating team members to be responsible for communication. Medical homes should be explained to patients in a culturally and linguistically appropriate way, patients should be matched with culturally and linguistically concordant providers and care teams, and team members should reflect the patient population.
The standard for identification and management of patient populations mirrors the meaningful use requirements for electronic health record incentive payments, Bau observed. It calls for the use of an electronic system that records race, ethnicity, and preferred language as structured (and thus searchable) data for more than 50 percent of patients, with the suggested proportion being 80 percent at a later stage. It also asks for information about family, social, and cultural characteristics and communication needs as part of a comprehensive health assessment. Who are the patient’s caregivers and support network? Who needs to be involved and informed about the patient’s care plan? Does the patient use the Internet? Does the patient use mobile technology? “All that is part of that assessment,” Bau said. This information can document granular demographic information, provide information about health disparities and additional relevant screenings, and identify cultural, linguistic, and literacy barriers to care for high-risk and high-need patients.
Every patient needs a care plan with individualized goals. This requires health care providers to engage the patient, family, and caregivers in the care plan and shared decision making about care. The care plan needs to be culturally and linguistically appropriate. Similarly, patients, families, and caregivers need culturally and linguistically appropriate tools to make informed decisions about treatment options. Bau explained that “our Western, American way of autonomy, where everything is about ‘my decision,’ isn’t going to work in a family context in which those decisions are made by the family, or the wife is deferring to the husband. So are you then engaging that entire family in the decision-making process?”
Making and sticking with a care plan will require time and an ongoing relationship with a medical home provider, said Bau. “You’re going to create it, you’re going to work on it, you’re going to change it, you’re going to continue to come back to it,” he added.
Making a shared plan for care that is centered on the patient requires that the patient and community be empowered. Providers and community health centers will need to address the social determinants of health over which they do not have much control but they can provide linkages, coordination, and referrals. The current standards are “gentle,” said Bau, and currently require the provision of educational resources or referrals to at least 50 percent of patients and families to assist with self-management, use of an electronic health record to identify patient-specific educational resources and provision of these resources to more than 10 percent of patients if appropriate, and maintenance of a current resource list on five topics or key community service areas of importance to the patient population. “It’s a start,” said Bau.
Effective self-care and community support are particularly challenging in the context of health equity because they require access to health information in multiple languages, channels, and formats and the use of community resources that are focused on diverse communities and health disparities. Community-based organizations have already done good work on patient-education materials that need to be in the hands of medical homes, said Bau. Community-based organizations such as mental health, substance abuse, and social services organizations must assess their role in health care reform. They need to ask their clients where they go for medical care. They then need to become partners with those providers, because the providers will not be able to offer all of the services expected of a medical home. “There is shared responsibility here. We all need to step up as well to offer the resources. If you are in the community, you need to be on that list of community resources that medical homes know about so that those patients can come to you for the services that they need,” he added.
The tracking and coordination of care is the heart of the medical home concept. When a provider makes a referral, is the specialist going to be able to speak the patient’s language? Will laboratory results be provided to the patient in a language and in a way that the patient can understand? A medical home will not necessarily be able to control other providers in the community, but a primary care provider has the obligation to be an advocate for patients vis-à-vis other providers.
That is one problem with the term “patient centered,” said Bau, adding that “in many of our communities, it’s not just about me as the patient. It’s about me, plus my family, the caregivers, and the community.” Care coordination recognizes these interdependencies by recognizing the
roles of families, caregivers, communities, and patients to better engage patients.
The driving force of patient-centered medical homes is outcomes. Does health get better? “We’re holding medical homes accountable,” Bau emphasized. Performance data need to be gathered and stratified for vulnerable populations in order to assess disparities in care. Furthermore, this process must start on Day 1 in the medical home so that feedback is immediate and continuous. This feedback also needs to come from patients and families through qualitative means. “We want specific feedback from those populations we usually don’t hear from and we usually overlook,” he said.
Medical homes need to implement continuous quality improvement to reduce disparities. This effort will require engaging patients and families in quality improvement teams or on a practice’s advisory council, oversampling vulnerable patients for feedback on their experience of care, improving the patient experience for vulnerable populations, and engaging diverse patients in improvement efforts.
Quality improvement programs save money, but the savings can be hard to demonstrate because of the complexity of life and health, said Bau. The goal needs to be to move practices along a quality improvement and equity continuum.
Patient-centered medical homes are being implemented in many different ways. For example, medical homes in Minnesota receive additional payments if they have a linguistically diverse patient base. Connecticut has made the reduction of racial and ethnic disparities a critical goal in its implementation of medical homes. In San Francisco, California, the Healthy San Francisco program, which provides health care regardless of immigration status or income, requires that patients choose a medical home, and the Healthy Way LA program in Los Angeles, California, takes a similar approach.
The answers will be different from one place to another, said Bau, depending on the stakeholders and the providers. He explained that “what Vermont can do is not what California can do. What San Francisco can do is not necessarily what Connecticut can do.” Markets may be based more on regions than on states or counties, though counties may work together to create regional systems.
Bau closed with four recommendations based on his experiences with patient-centered medical homes:
- Educate diverse and vulnerable patients, families, and caregivers about medical homes and engage them in the use of medical homes.
- Highlight opportunities to reduce disparities and promote health equity, including the establishment of additional requirements and payments, when establishing medical home initiatives.
- Each patient-centered medical home should monitor the NCQA standards specific to health equity to ensure compliance with these standards. The NCQA framework is still evolving, and issues such as patient-centered care and equity require continued advocacy.
- Develop and disseminate technical assistance to medical home practices to achieve health equity.
Providers have an uphill climb to become a medical home, Bau said. They need assistance, guidance, and support to achieve the promise of health equity as they move toward this new vision of health care.
“In many of our communities, it’s not about me as the patient. It’s about me, my family, the caregivers, and the community.”
The ACA is like a roundhouse with many trains (that is, the law’s provisions) that are leaving and heading in different directions and at different speeds, said Dennis Andrulis, senior research scientist at the Texas Health Institute and associate professor at the University of Texas School of Public Health. Some of the trains are barely moving, whereas others are roaring down the tracks. The provisions of the ACA are filled with variation, he said, “and those variations are fraught with both opportunity and concern.”
The Texas Health Institute has been monitoring about 60 provisions related to race, ethnicity, equity, language, and culture that are part of the ACA, with a particular focus on five broad areas:
- Health insurance exchanges;
- The health care safety net;
- Workforce support and diversity;
- Data, research, and quality; and
- Public health and prevention.
Reports are being released in each of these areas and the report on health insurance exchanges—the first in the series—was released 1 month before the workshop (Andrulis et al., 2013). That report, which synthesizes information from interviews, the literature, and other sources, cited Connecticut as one of the states that has done the most to establish health insurance exchanges. It also provided recommendations for states that are actively moving ahead and for those states that are lagging behind.
Ten provisions in the ACA explicitly mention “health homes” or “medical homes.” Those 10 provisions also specify priorities for advancing racial and ethnic equity. Andrulis divided these 10 provisions into four categories: state actions, workforce and delivery of care, research and innovation, and insurance and payment. Some of these trains are already leaving the station, he said, whereas others have not made it out of the gate.
The ACA created a state option to provide health homes for Medicaid enrollees with chronic conditions. At the time of the workshop, 10 states had approved health home plans: Idaho, Iowa, Maine, Missouri, New York, North Carolina, Ohio, Oregon, Rhode Island, and Wisconsin. Currently, equity activities in state health homes include the provision of culturally and linguistically appropriate patient communication and individual and family support, evidence-based culturally sensitive wellness and prevention activities, and patient health assessments that include measures of language and cultural factors. States that have undertaken these activities can qualify for 2 years of enhanced federal funding to be used for the development of coordinated care for patients with chronic conditions and patients with mental illness.
Though the advantages of health homes that focus on chronic conditions or mental illness have not yet been demonstrated, Andrulis said, these initial steps to target specific populations may be of value. In particular, information from these initial steps can inform efforts in other states.
Under the ACA, states with Medicaid 1115 waivers1 that explicitly focus on health system restructuring may consider using matching funds to test health homes for diverse patient populations. Some states are using this provision to undertake initiatives not directly supported by the ACA, such as using community health workers to support health homes and advance equity.
1 Medicaid 1115 waivers are granted by the Secretary of HHS to states that want to create demonstration or pilot projects. This is so the state will have added flexibility to design and improve their Medicaid programs.
Several provisions of the ACA link health homes directly to workforce development and service delivery. One example is the use of funding from the Health Resources and Services Administration for training, curriculum development, and continuing education for primary care residencies and physician’s assistants. Another example is the use of health extension agents in four states (New Mexico, North Carolina, Oklahoma, and Pennsylvania) to further the adoption of medical homes that prioritize cultural competency and the use of the patient’s language.
Andrulis suggested that three areas related to equity should be monitored within workforce and delivery initiatives. The first area is to evaluate training curricula. How are cultural competency, language, and health literacy addressed in training providers in implementing health homes across professions? The second is to identify supportive best practices. What actions support equity in health homes? The third is to measure equity-focused processes and outcomes. What are the effects of these initiatives on patient satisfaction, quality improvement, disease management, and treatment adherence?
Another opportunity to advance racial and ethnic equity through the workforce and the delivery of care is the expansion of health home and equity programs to other practice settings supported by the ACA, including teaching health centers, nurse-managed clinics, and school-based health centers. For example, Maryland is coordinating its workforce efforts with the Governor’s Health Care Reform Coordinating Council to improve access to care and highlight team-based approaches to care.
One of five research priorities for Patient-Centered Outcomes Research Institute (PCORI) (see Chapter 6) is health disparities. In addition, the CMS Innovation Center has been making grant awards for research on primary care, payment, and delivery, though relatively few have explicitly addressed racial and ethnic equity. Andrulis also cited the Advanced Primary Care Practice demonstrations as an opportunity to make progress on equity issues.
Evaluations could consider disparities in outcomes at different health homes, the metrics used to evaluate the effects of interventions to achieve equity in health homes, and short-term as well as long-term outcomes. Other community initiatives funded by the ACA may yield progress on these issues. For example, Community Health Needs Assessments (see Chapter 5) can provide both information and support for goals such as the establishment of medical homes.
The trains have been much slower to leave the station in the areas of insurance and payment, Andrulis said. The ACA encourages health plans offered through the exchanges to incentivize providers to improve health outcomes by adopting health homes or taking other actions to reduce disparities, though little or no federal guidance has been provided thus far. Rules on quality reporting in health plans that reimburse providers for the use of health homes are expected, but the focus has been on getting the health plans offered through the exchanges up and running.
The overriding need is to integrate and align key features of medical homes with the plans offered through the exchanges and active purchasing to advance equity, said Andrulis. For example, exchanges opting to be “active purchasers” may require health plans to implement quality improvements that include quality reporting, establishment of the features of health homes, and the actions that they will take to address racial and ethnic disparities in health and health care. Another promising option is to encourage pilot payment programs to test new patient-centered models of care, including health homes that disproportionately serve diverse patients.
Andrulis mentioned several challenges determined, in part, from conversations that he and his colleagues have had with people around the country. Currently, many people tend not to see issues around diversity, disparities in health and health care, and equity as a priority to be addressed through the ACA. As a result, these issues tend to be overlooked or equity provisions are not well funded.
The complexity of the ACA has also detracted from the necessary discussion around diversity and cultural competency, said Andrulis. People tend to be overwhelmed by what the ACA is asking them to do and are struggling with change at a broader level. Deadlines are looming, and guidelines are insufficient. Political forces are also hard to predict and control.
Furthermore, some health care providers are engaged in competition rather than collaboration. For example, an important incentive for community health centers is enrollment, and some centers are concerned about losing their base. As one safety net interviewee stated, “How do providers navigate this new system while keeping their souls intact?”
Finally, Andrulis mentioned the issue of siloes. Currently, hospitals are focused on procedures like surgeries, not on prevention. “There are these business silo elements that need to be considered,” he said.
Again, Andrulis mentioned several key areas to monitor.
Policy and Advocacy
- State-level uptake of health homes and integration of equity objectives
- Federal guidance and rules for health homes and integration of equity
Research and Innovation
- Integration of equity into announcements of funding opportunities, outcomes research, and metrics on health homes
- Inclusion of metrics on health homes by race and ethnicity, for example, continuity of care, access, quality, disease management, and adherence
Workforce and Delivery
- Training in cultural competency and diversity in health homes
- Impact of scope-of-practice laws in states on health homes and access for diverse patients
Payment and Exchanges
- Market-based incentives for health homes and reductions in disparities in health and health care
- State active purchasing requirements2 and the inclusion of health homes and equity
Efforts to break down siloes and integrate care are still at a small-scale, demonstration level. States will eventually have to take the next step. Active purchasing may be a small step, Andrulis observed, but it is a step in the right direction. Some safety net providers are aggressively pursuing opportunities for change and transformation, and some hospitals are trying to move toward community-based and integrated care, but the examples are still rare.
It is still early in the process, Andrulis said, adding that “this is such a major redirection of the health care world. Don’t look so much to the past. Look to what’s coming out.”
2 Active purchasing in those states with state-based exchanges means that those states must help organize the insurance marketplace and promote competition among health plans.
“This is such a major redirection of the health care world. Don’t look so much to the past. Look to what’s coming out.”
Cheri Wilson of the Center for Health Disparity Solutions at the Johns Hopkins Bloomberg School of Public Health asked the first question, which focused on the NCQA standards. She wondered why those standards did not incorporate the NCQA multicultural health care standards into the overall framework. Bau responded that this is an evolving concept, and what is needed is to advocate that NCQA incorporate the patient-centeredness and equity pieces into the overall framework.
Ned Calonge of The Colorado Trust asked about the fact that in his home state (Colorado), the hospitals there are still concerned about “filling their beds.” Andrulis raised the idea of an active purchasing model that might be a place to begin. Additionally, Andrulis believes that some hospitals are recasting themselves toward more community-based care. Andrulis also noted that the readmissions issue was one potential trigger for hospitals.
The final question was about the concept of a “neighborhood home.” A participant wondered how local agencies and community-based organizations can get a seat at the table.
Bau responded that the best way to begin is to ask the organization’s clients where they receive medical services. Those clinics can then become a partner with the community organizations.