September 5, 2014

The patient-centered medical home has become one of the defining approaches to health care delivery transformation of this decade. Many claims have been made about the PCMH: It will improve quality. It will decrease costs. It will transform care into “what patients want it to be.” (No, really. That last one is actually from the National Center for Quality Assurance.) But emergency medicine should be particularly interested in the claim that it will reduce unnecessary emergency department visits, easing the burden on crowded EDs.

Hospitals, health systems, and physician practices are rushing to earn recognition as a PCMH from the NCQA, URAC, the Joint Commission, or the Accreditation Association for Ambulatory Healthcare, but how much do we know about whether any of these promises will actually materialize and in what timeframe, especially the one about ED visits?

As the evidence shapes up, it appears that one size does not fit all. A study in the Feb. 26 Journal of the American Medical Association —one of the largest and longest-running studies of PCMH practices in the United States — found that PCMHs were not associated with reductions in total cost of care or in hospital, ambulatory care, or emergency department use.

The reviewers analyzed data from 64,243 patients treated between June 2008 and June 2011 at 32 primary care practices that shifted to a PCMH model in 2008. (JAMA 2014;311[8]:815.) Only one of 22 measures — nephropathy monitoring — was significantly better in the PCMH setting. And that included four ED-related indices.

The study, wrote Thomas Schwenk, MD, of the University of Nevada School of Medicine in an accompanying editorial, “effectively end[s] promotion of this care model as a generic, low-level, unselective approach to health care delivery for all. The next critical phase of PCMH development should focus on its strategic deployment for the care of high-utilization patients.”

Two recent studies demonstrating successful reduction in ED use associated with PCMH implementation appear to support that point; specific populations particularly likely to benefit from a PCMH model of care were involved in both cases.

“A middle-aged person on one or two medications who sees his or her doctor once in a while, they don’t need the kind of intensive surrounding care that the medical home can provide,” said Krisda Chaiyachati, MD, MPH, a chief resident in internal medicine at the Yale School of Medicine and a former resident at the VA Center of Excellence in Primary Care Education Clinic in West Haven, CT. “But there are groups of patients that we might call high-risk populations — people with low socioeconomic status and a lot of comorbidities — who can benefit.”

One of those populations, Dr. Chaiyachati said, is military veterans. He and colleagues found that patients with continuity of care under the VA’s PCMH model had lower ED utilization compared with individuals without continuity, controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. (PLOS One 2014;9[5]:e96356.)

“We never can account for individuals who have a true emergency like a heart attack at 2 a.m. That’s what the ED is for,” Dr. Chaiyachati said. “But it’s that intermediate zone we’re trying to reach. We describe them as primary care sensitive, diagnoses that could have been handled in a PC visit. The goal is to create access points for these high-risk patients where they feel comfortable seeking care within the primary care system. If they’re in a system where the structure and design aren’t apparent and they feel like they’d see someone who wouldn’t know them anyway, I could see that the patient might feel that he might just as well go to the ED.”

A study presented at the recent annual meeting of the Society for Academic Emergency Medicine found a similar lack of benefit for medical homes. Brian Raffetto, MD, an emergency medicine resident at LAC-USC, and Peter Balingit, MD, an internist at Olive View-UCLA Medical Center, analyzed utilization of episodic care services from June 2009 to May 2012 by patients enrolled in a medical home pilot. No benefit was seen in reducing hospital care.

Kelly Doran, MD, an instructor in emergency medicine and population health at New York University School of Medicine, wrote a chapter on the PCMH in the 2012 edition of the Emergency Medicine Residents’ Association’s Emergency Medicine Advocacy Handbook. She is skeptical of just how much of an impact it can have on ED use.

“Part of the problem will always be access,” she said. “The ED is there 24 hours a day, seven days a week. One of the components of PCMH is improved access, but the degree to which that is happening in a real way — availability after hours, at night, and on the weekend when patients want it — is more theoretical than real, at least right now.”

That’s something that the Group Health PCMH initiative in Washington state is trying to address through intense focus on improving access, although not always face-to-face access.

“Group Health deployed a much wider array of modalities around contacting patients and dealing with their concerns through telephone or secure email,” said Robert J. Reid, MD, PhD, a senior investigator at the Group Health Research Institute and its medical director for research translations. “We ask patients to call our own internal consulting nurse service. They have full access to our EMR, and they’re able to work with the patient to understand what the problem is and the potential for resolution. They can make next-day appointments at the doctor’s office and set up test ordering.”

It appears to be working: Results from an ongoing study of the Group Health PCMH found that emergency visits were 13.7 percent less among patients assigned to the pilot PCMH clinics than among other patients during the first year of the program and 18.5 percent less in the second year. (Ann Fam Med 2013;11[Suppl 1]:S19.)

A challenge to understanding the effectiveness of the PCMH model in reducing ED visits — or achieving any of the model’s stated goals — is the amorphous nature of the term. “There is a real diversity in what a PCMH is. In general, there are some key principles that people try to enable in different ways, that signify a patient-centered medical home, but there’s a wide spectrum of capabilities, strategies, and where practices are at baseline,” Dr. Reid said. “The heterogeneity of research results reflects differences in what’s being done in these demonstrations, where practices were at the beginning, and how long it really takes for change to happen. Transformation of practices is a difficult process that can play out over years.”

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Wolters Kluwer Health | Lippincott Williams & Wilkins


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