The medical home: A need for collaborative practice

The patient-centred medical home (PCMH) is an alternative way of delivering primary health care, previously described in Australian Family Physician (AFP)¹ and The Royal Australian College of General Practitioners’ (RACGP’s) clinical guidelines.² The PCMH has implications for how healthcare professionals work together, leadership and training.

I was in Minnesota, US, in 2014 and 2016, exploring changes in US primary care clinics, with an emphasis on inter-professional education (IPE), which is my area of expertise.³ I found the PCMH model to be fairly well established in many states in the US, where healthcare is delivered through collaborative practice. Currently, the delivery of healthcare in the US is more expensive than in other high-income countries, without better outcomes.⁴ There is growing evidence that PCMHs reduce costs and achieve better health outcomes⁵ through improved relational continuity of care⁶ and an interprofessional approach. Such team-based care requires training in the PCMH setting itself⁷ (as part of continuing professional development) and in pre-qualification health professional programs. While IPE is a feature of many universities in the US, there is still an over-reliance on uniprofessional teaching,⁸ similar to the situation in Australia.⁹

The Patient-Centered Primary Care Collaborative (PCPCC) emphasises that PCMHs are ‘coordinated, accessible, and focused on quality and safety’.¹⁰ To deliver this model, the US fee-for-service payment system is not considered appropriate.¹¹ Bundled payments have therefore been introduced; this is similar to the system proposed for Australia, with multimodal remuneration, including registration fees and aligning incentives with patient outcomes.¹² Unlike most Australian general practices, health workers in US PCMHs are co-located, while a named primary care provider (PCP) is the patient’s main point of contact. Controversially, in contrast to current practice in many systems, the PCP is not necessarily the physician, who has traditionally taken the leadership role in healthcare provision. Instead, the family physician, or general practitioner (GP), is one of the team and is available for more complex consultations. There are electronic shared medical records, which may be accessed by patients.

My concern is that many Australian health professionals are not trained for collaborative team-based practice¹³ ‘when multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care [and] health workers engage any individual whose skills can help achieve local health goals’.¹⁴ In my opinion, such practice goes beyond Australian team-care arrangements that do not foster interprofessional communication. Allied healthcare is still predominantly a private enterprise with little opportunity or incentives for collaboration. The requirements of team-working are not met, in that practitioners do not meet to discuss patients’ goals and review progress.¹⁵

I believe PCMHs have the potential to improve healthcare if health professionals can be co-located and overcome turf battles. Australian healthcare accreditation bodies, including those for medicine, now have mandatory IPE standards.¹⁶ There is a need for appropriate clinical placements modelling team-based care. PCMHs will therefore have an important role in ensuring all students and practitioners ‘learn together to work together’.¹⁷

Author

Jill E Thistlethwaite BSc, MBBS, PhD, FRCGP, FRACGP, MMEd, DRCOG, Health Professional Education Consultant and General Practitioner, Sydney, NSW; Adjunct Professor, University of Technology Sydney, Ultimo, NSW. jill.thistlethwaite@uts.edu.au

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.

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