Family medicine clinics provide 'medical home' for patients

Complete care

As a patient with multiple sclerosis who sees a number of doctors, Christine Abbott used to feel a disconnect among them about her health care. About four years ago, though, she started going to the Family Medicine Clinic at Medical College of Georgia Hospital and Clinics, where her providers began talking to one another and sharing information.


“When I go into Family Medi­cine, they have the whole picture of me, which my community physician did not have,” Abbott said. “I’m more confident that everyone is on the same page.”

Abbott and others benefit from the clinic’s embrace of patient- and family-centered care and from a concept called “patient-centered medical home,” a distinction a clinic can earn from the Na­tional Committee for Qual­ity Assurance for meeting standards for access, care management, outcome monitoring and quality of care.

There are 4,220 practices in the U.S. that have earned the distinction, with 26 in Georgia and three in Richmond County: Family Medicine at GHSU, Family Medicine at Fort Gordon and the Center for Primary Care.

Practices have to meet those standards to be called a patient-centered medical home, but it is not an end in itself, said Dr. Joseph Hobbs, the chairman of Family Medi­cine at GHSU.

“To me, patient-centered medical home is a tool that was used for us to be able to deploy effectively patient- and family-centered care and to deploy effectively population-based care and management and be responsible for all of those things,” he said. “The PCMH is a tool that permits us to apply those concepts to our practices because we believe those concepts can improve not only patient satisfaction but the quality of services we deliver, and health outcomes in general.”

Complete care

The concept of patient-centered medical homes first surfaced in pediatrics in the 1960s and was more recently embraced by primary-care associations as the need for continuity of care became more apparent, said Dr. Frank Don Diego, the academic chairman and program director of the Floyd Family Medicine Residency Program in Rome, Ga. It is a comprehensive, team-based approach in which the practice takes on the responsibility for coordinating and improving care, he said. That means thinking about the patient outside of the exam room and beyond the last appointment, Hobbs said.

Physicians, nurses, front-office workers and everyone else in the office must be retrained to take on different roles in providing and coordinating that care, Don Diego said.

“It does take a lot of training,” he said at a recent meeting of the Association of Health Care Journalists. “It does take a lot of teamwork.”

For instance, practices usually have to hire a care coordinator who tracks the records and keeps an eye on the bigger picture, even if it is not reimbursed care, Don Diego said.

“We’re doing a lot of work without” reimbursement, he said.

That is part of a larger problem with primary care in general, said Dr. David Satcher, of the Satcher Health Leadership Institute at the More­house School of Medi­cine.

“Primary care has been, in our system, devalued,” he said. “And now we’re paying a price for that.”

There had been plans for enhanced fees for patient-centered medical homes but that has yet to happen and should not be the motivation for pursuing the designation, Hobbs said.

“My motivation was the realization that in order to appropriately accept the responsibility of the population of patients that is assigned to us, that we needed to put together a different infrastructure that would use new tools and maximize the functionality of old tools to provide us data about how well we did,” he said.

Cutting costs

The clinic at GHSU has had an electronic health record for years but wasn’t fully taking advantage of all its functions, Hobbs said. The clinic is working on getting patients greater access to their health data through an online portal, but for some that won’t be appropriate and they will continue to get mailed information to help them manage their conditions, he said.

Studies show that people with chronic conditions usually receive about two-thirds of the care they need, in part because of disparate care, Don Diego said.

Providing better care through a patient-centered medical home has been shown to reduce hospitalizations and visits to the emergency room, which reduces cost, Don Diego said.

“This is dollars,” he said. “This is why people want this.”

That drives clinics to make the difficult transition from focusing on the volume of patients seen to focusing on patient outcomes, Hobbs said.

“You’re being evaluated by the quality of services you deliver,” which is what patients expect, he said.

For Abbott, it is as simple as her primary care doctor knowing that one of the neurology drugs she takes has a side effect of causing diabetes in some patients.

“(The doctor) can start keeping an eye on the diabetes aspect and help me with counseling and the things I need to do,” she said. “Everything I take has a side effect. Most of it, I can manage with diet and exercise. They are much more in tune to what I need personally.”