The PCMH, PCMH-N and ACOs: What is the Question?

In the spirit of the game Jeopardy, what is the question that the patient-centered medical home (PCMH), PCMH-Neighbor (PCMH-N), and Accountable Care Organization (ACO) are trying to answer? From my perspective, these concepts and the attempts to build, test, and improve them are in response to the question:

How can we fundamentally change our healthcare delivery system to…

  1. Revitalize the healing and trusting relationship between a healthcare professional and his/her patients.
  2. Respond to patient & family needs.
  3. Organize itself around the concept of patient-centered care.
  4. Practice to the available evidence where such guidance exists.
  5. Contribute to health services research to identify the best modes of treatment for people with complex healthcare needs.
  6. Integrate behavioral health, mental health, and wellness/promotion into primary care.
  7. Achieve Dr. Berwick’s Triple Aim for healthcare: improve the health of populations; improve the experience of care; reduce per capita costs?

I recognize that the expectations of a redesigned healthcare delivery system go well beyond the brief list above. For example, these models of care cannot, independent of broader system changes, respond to the challenge of insurance coverage, workforce shortages, and access to care.

The PCMH is a model for reorganizing/redesigning the way in which primary care is delivered in the United States — with specific recommendations at the micro (practice) level that have potential implications at the macro (community/society) level. However, the PCMH will not be sufficient to achieve Dr. Berwick’s Triple Aim or many of the other goals we have for the future of the healthcare system. To do so will require broader change involving specialty/subspecialty care, hospitals, long-term care facilities, and health professionals and providers beyond physicians, nurse practitioners and physician assistants. In other words, it will take not just a medical home, but the entire “neighborhood.” The PCMH Neighbor (PCMH-N) concept was recently advanced by the American College of Physicians. The Annals of Internal Medicine subsequently published two perspectives (here and here).

As a concept, the PCMH-N and PCMH describe an integrated, efficient way of providing patient-centered care. Success will be, in part, dependent on: a) further development of these concepts; b) changes in the culture of healthcare delivery; c) design and implementation of health information technology that facilitates the model; d) alignment of incentives to ensure that all of the relevant stakeholders are supported through the transition; and e) an appropriate long-term sustainability model based on the assessment of the cost, quality, and experience of care generated by demonstration programs that incorporate the PCMH & PCMH-N.

The PCMH/PCMH-N model can, and perhaps should, serve as a foundation upon which ACOs are built. In fact, the ACP, AAFP, AOA, and AAP recently released a set of principles to guide ACO development calling for just such an approach. ACOs could fulfill the functions (e.g., clinical support staff such as care coordination, informatics) — as well as the organizational framework — often lacking among small/medium-sized independent practices. Collectively, the PCMH, PCMH-N and ACO concepts may represent the best opportunity to achieve the desired future for the United States healthcare delivery system.

Want more resources?

This is clearly not an exhaustive list — even though I’ve tried to identify sources of sources, so please let me know if you have a favorite aggregator of relevant resources.

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.

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