Vulnerable populations

2016

Up front

The medical home: A need for collaborative practice

Volume 45, No.10, 2016 Pages 759-760

Jill E Thistlethwaite

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.

References

  1. Kellerman R. The patient centred medical home. Aust Fam Physician 2009;38(5):279.
  2. The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part A – Clinical governance framework. East Melbourne, Vic: RACGP, 2015. Available at www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-a [Accessed 4 May 2016].
  3. Thistlethwaite JE. Interprofessional education: A review of context, learning and the research agenda. Med Educ 2012;46(1):58–70.
  4. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: How the U.S. health care system compares internationally. New York: The Commonwealth Fund, 2014. Available at www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror [Accessed 4 July 2016].
  5. Nielsen M, Langner B, Sema C, Hacker T, Grundy P. Benefits of implementing the primary care patient-centered medical home: A review of cost and quality results. Washington DC: Patient-Centered Primary Care Collaborative, 2012. Available at www.pcpcc.org/sites/default/files/media/benefits_of_implementing_the_primary_care_pcmh.pdf [Accessed 4 May 2016].
  6. Coleman K, Reid R. Continuous and team-based healing relationships: Improving patient care through teams. In: Phillips KE, Weir V, editors. Safety net medical home initiative implementation guide series. 2nd edn. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute, 2013.
  7. Schottenfeld L, Petersen D, Peikes D, et al. Creating patient-centered team-based primary care. Rockville, MD: Agency for Healthcare Research and Quality, 2016.
  8. Schuetz B, Mann E, Everett W. Educating health professionals collaboratively for team-based primary care. Health Aff 2010;29(8):1476–80.
  9. The Interprofessional Curriculum Renewal Consortium. Curriculum renewal for interprofessional education in health. Sydney: University of Technology Sydney, 2013.
  10. Patient-Centered Primary Care Collaborative. Defining the medical home. A patient-centered philosophy that drives primary care excellence. Washington, DC: PCPCC, 2015. Available at www.pcpcc.org/about/medical-home [Accessed 4 May 2016].
  11. Safety Net Medical Home Initiative, Bailit M, Phillips K, Long A. Paying for the medical home: Payment models to support patient-centered medical home transformation in the safety net. Seattle, WA: Bailit Health Purchasing and Qualis Health, 2010. Available at www.co.fresno.ca.us/viewdocument.aspx?id=47520 [Accessed 4 May 2016].
  12. Ernst & Young, WentWest Limited, Menzies Centre for Health Policy. A model for Australian general practice. The Australian person-centred medical home. Sydney: Ernst & Young, 2015.
  13. Chester J, Burley M. Beyond professional conflict. In: Kitto S, Chesters J, Thistlethwaite JE, Reeves S, editors. A sociology of interprofessional healthcare practice: Critical reflections and concrete solutions. New York: Nova, 2011; p. 105–18.
  14. World Health Organization. Framework for action on interprofessional education and collaborative practice. Geneva: WHO, 2010.
  15. Reeves S, Lewin S, Espin S, Zwerenstein M. Interprofessional teamwork for health and social care. London: John Wiley and Sons, 2010.
  16. The iTOFT Consortium. Work based assessment of teamwork: An interprofessional approach. Canberra: Office for Learning and Teaching, 2015.
  17. World Health Organization. Learning together to work together for health. Geneva: WHO, 1988.

Correspondence afp@racgp.org.au

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