The Patient Centered Medical Home (PCMH)

Yesterday I got around to reading through the September issue of Translational Behavioral Medicine. It was a special section on something called the Patient Centered Medical Home or PCMH for short. This is a huge topic and I will probably make a series of posts about it in the coming weeks.

For now, I just want to start with what PCMH is and why you should care as a patient, provider, and even researcher. Well for one it is a current buzzword, and as silly as buzzwords can be, it helps to know them. But behind that, I actually think some of the foundational ideas are great. It remains to be seen what the implementation looks like, but I am hopeful.

So what is a “Patient Centered Medical Home”? The Agency for Healthcare Research and Quality defines it as, “not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care” (AHRQ). That definition has to win an award for circularity. Here is my take.

Health is complex and many patients, particularly those with chronic disease, see many providers. They have specialists to manage all of their conditions, they get lab work, they see primary care providers, etc. Traditionally, each of these units have been separate and done a poor job of communicating and coordinating with each other. This leaves many patients feeling overwhelmed and can lead to unnecessary mistakes (Singh and Graber, 2010) or patients slipping through the cracks because needed information was not properly conveyed either to patients or between providers. The idea behind the PCMH is to better organize and deliver care. That means everyone integrating and talking together and everyone includes the patient.

All that may seem obvious, but the traditional medical model grew out of a system where doctors looked at patients, made a diagnosis, and then made some prescription for some treatment (medication or otherwise). Recently, there is a shift to include patients more in decision making, to discuss options with them, and to try to make sure they really understand what is going on. Part of this is due to a shift in the problems we are facing. Earlier, infectious diseases and injuries were primary killers. These were acute problems with (usually) an acute treatment (I know I am generalizing here, but bear with me). Now, chronic diseases such as cardiovascular disease, cancer, diabetes, etc. are becoming bigger and bigger problems relative to other illnesses. These are chronic. This means that patients really need to be involved in their own care. They cannot just come to a hospital for a few days and leave better. Once patients are going to be taking part in their own treatment, it becomes paramount that they not only understand the treatment and what to do, but that they are able to do it. It is no good to tell someone take this pill three times a day and exercise, if the patient only takes it once a day and exercises sporadically. In that case, a better plan needs to be made that does the best possible for the patient given what he or she will realistically do.

Chronic problems such as cardiovascular disease or cancer often involve many specialists too. A patient may have a surgeon, primary care provider, radiation oncologist, and others. To make sure the patient gets the best care, all of these people must work together, share information, and coordinate including the patient at every step. That, I think, is the core of PCMH.

So why should researchers care? PCMH offers the possibility to really implement evidence based practices. This applies both to medicine and the biomedical sciences but also the behavioral. There is a host of research on adherence to treatment, exercise interventions, smoking and other drug cessation interventions. All things that are vitally important to patient health, particularly in the context of chronic disease. Psychology and related fields have studied these areas extensively, but implementation in practice remains poor. The PCMH with its focus on engaging the patient and improving communication offers a real opportunity for behavioral research to play a role in understanding and evaluating what does and does not work. The importance of patients in their own care and doctor-patient communication has never been higher. There is a nice article on this here by Kessler, 2012. I think/hope it is open access.

As I mentioned, this is an important enough and broad enough topic I will probably be posting more on it in the future. Particularly with a focus on what psychology and behavioral researchers can bring to the table. One final useful link from the American Academy of Family Physicians (and others) Guidelines for Patient-Centered Medical Home (PCMH) Recognition and Accreditation Programs.

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