Hitting a Home Run:
The Patient Centered Medical Home and
Home Care
This paper has been prepared by the Home Care Alliance of Massachusetts to support home health agencies seeking to
align with community health centers and physician practices in Massachusetts to support the transition to a medical
home model. It incorporates research on medical homes, current home health practice, as well as work done in 2009
by the Massachusetts Patient Centered Medical Home Coordinating Committee.
Momentum is building in Massachusetts and elsewhere around the country to reconfigure primary
care physician practices towards a “medical home” model targeted at reducing care fragmentation
and better managing costly chronic diseases. Massachusetts is one of several states that has
received a grant from the Commonwealth Fund to implement the Patient Centered Medical Home
(PCMH). In 2010, this grant is expected to support PCMH implementation in at least a dozen
selected community health centers. Additionally, the state FY 2010 budget included funding for a
PCMH pilot in selected primary care practices. The long term goal is a very broad statewide
transformation of primary care practice into a PCMH model that encompasses all payors and
patient types with demonstrated effectiveness, both in terms of improved clinical outcomes and
cost savings.
The movement toward a medical home depends on the state developing a set of core competencies
and transformation strategies that will define and move current primary care practices towards a
PCMH. These competencies and trainings are drawing on work done in other states, as well as the
National Committee on Quality Assurance’s (NCQA) Standards and Guidelines for PCMH.
However, Massachusetts expects to develop our own framework for implementation that works
for Massachusetts. Essential components will include patient centeredness, smooth transitions
across care settings, integrated care teams, patient self management coaching of patients with
chronic diseases, case coordination and care management. Although many medical home models
don’t specifically emphasize or articulate a strategy to make the home an actual site of care,1 many of
the strategies Massachusetts is looking to (e.g., managing patients one-on-one, reducing costly and
unnecessary office visits, engaged families and empowered patients) can all be linked to the home
care model. Therefore, there is great potential for practice transformation to a PCMH to be
accomplished for physician groups by building on or reconfiguring existing home care relationships
to meet the state’s expected practice parameters.
This paper uses some of the tenets of a PCMH to present an overview of the skills and qualifications
that home health care agencies could bring to a possible PCMH partnership.
PCMHs will need Chronic Care Management and Patient Self Management Programs
For a PCMH to be successful, the management of chronic disease must ultimately occur in the patient’s
home, not necessarily in the practice office. Despite restrictive rules and coverage limitations in caring for
Medicare beneficiaries with chronic illnesses, many home health agencies have participated in CMS Home
Health Quality Improvement (HHQI) pilots and projects to redesign their routine care plan services to
incorporate and in some cases become certified in evidence-based chronic care management models (e.g the
Wagner and Coleman models) and patient self management (Stanford Model). Several agencies now have
Certified Diabetic Educators (CDEs) on their staffs Close to half of the state’s home health agencies have
remote vital sign monitoring capacities, and more than half use electronic medical records, both of which
could be central part of a medical home’s data driven chronic care strategy. Additionally, all certified home
health agencies have experiencing in assessing patients and their homes for basic human needs such as food,
hygiene, and safety and in connecting patients with community supports. PCMHs will need all of these
skills.
PCMHs Will Need To Provide 24/7 Care
Practice infrastructure redesign is among the biggest challenges of conversion to a PCMH, especially for
small practices. A recent evaluation of practice readiness in Massachusetts2 found that the least common
capability among practices was being regularly open to provide care on weekends (24%). On the
contrary, home health agencies have significant experience in operating in a 24/7 environment as
required by the Medicare Conditions of Participation. In this role, home care agencies routinely
coordinate care among multiple physicians, assist patients with medication adjustments, and
provide follow-up care and counsel after hours.
1
Landers, Steve; The Other Medical Home, Journal of the American Medical Association, January , 2009
2
Freidberg, Mark W, et al; Readiness for the Patient-Centered Medical Home: Structural
Capabilities of Massachusetts Primary Care Practices Journal of General Internal Medicine, December 3,
2008
2
An essential PCMH performance measurement may well be their success in keeping patients out of
hospitals and emergency rooms on evenings and weekends. Since many practices may find 24/7
operation to be too onerous, models may be considered that share resources of home heath on-call
nurses and specialists to perform this essential function.
PCMHs will Need to Integrate Care Management into their Practices
The Geisinger and Mayo Clinic sites are often cited as models of integrated, patient centered care. Less
recognized, but equally successful, has been pioneering work of Baptist Health in Little Rock, AK, which
has been on the forefront of work using a home-based chronic care model. Based on work by Dr. Edward
Wagner, the Baptist Home Health Network’s Home-Based Chronic Care Model demonstrates how a
practice can make home care the center of care management and cost efficiency. The model incorporates
Wagner’s work on patient-centeredness and shared responsibility; but it also incorporates telehealth
technology to keep clinical information flowing and current. Importantly, the model capitalizes on existing
relationships that local home care agencies have with physicians, hospitals, insurance case managers and –
most importantly - patients with chronic disease. It has proven successful. Baptist Health’s Home Based
Chronic Care Model3 has cut that system’s rehospitalizations almost in half and won Modern Health Care’s
2008 Spirit Award.
With innovative leadership, local home care agencies could easily retool their staff and operations to help the
state and certain practices avoid the costly construct of a new care management system and thus help to
achieve a much quicker return on investment in a PCMH.
Strong Physician Home Health Agency Relationships Exist as a PCMH
Building Block
A survey conducted in Fall 2008 by the Massachusetts Medical Society survey showed that a vast majority of
physicians believe home health care services provide multiple advantages in improving health care quality
and reducing care delivery costs. 89 percent of responding physicians indicated an opinion that home health
services can reduce inpatient hospital admissions, 63 percent said that they reduce emergency room visits,
and 41 percent indicated that they can produce overall costs savings. When the survey looked at responses
by specialty, the connection between primary care and home care in this state was clear: 64% of primary
care physicians indicated using home health for chronic disease management; and 82% of primary care
physicians indicating using home care for hospice and palliative care .
Physician respondents were clear that relationships with home health care agencies (see graph below) are
important to efforts to achieve better patient compliance with a care plan (78%) and to stress reduction on
the part of patient’s families (72.9%)
The value in these relations may only grow with the trend in home care agencies to develop specialists in
such areas of high incidence disease states, such as certified diabetes educators, wound, ostomy and cardiac
nurses, and palliative care specialists.
3
The Center for Excellence in Chronic Care Management, HealthcarePromise™ A Blueprint to Deliver the
Promise of Healthcare Reform, Center for 2020 Solutions, Little Rock, Arkansas
3
In your opinion, what are the main advantages to using home health care
services in your practice?
80.0
78.3
72.9
70.0
65.0
62.9
60.0
50.4
50.0
%
188
40.7
175
40.0
156
151
30.0
121
20.0
98
10.0
1.7
4
0.0
Better com pliance
with care plan
Stres s reduction
patients '
caregivers
Better coordination
of care
Reduction in ED
vis its
Fas ter recovery
pos t-acute care
Cos t s avings
Not fam iliar with
thes e policies
Source: Mass Medial Society Survey of Physicians and Home Care, August, 2009
Conclusion
Studies are just beginning to appear that provide solid evidence as to whether and how the PCMH can
deliver on the promise of reducing costs by improving care quality and coordination. At least one previously
published study of disease management provides both a cautionary and supportive tale as to the home
health/physician partnership as a possible success factor in a PCMH. Mathematica’s recent Report to
Congress on the Evaluation of the Medicare Coordinated Care Demonstration indicated that
none of the 15 demonstration sites lowered overall costs and illustrated “the difficulties of reducing the need
for expensive medical care among beneficiaries with chronic illnesses.” The findings did identify some
characteristics across the most “potentially effective” programs. Among their conclusions were that:
“in-person contacts, whether in the patient’s home or at a physician’s office or clinic, help establish the trust
and rapport needed for the patient to be responsive to the care coordinator’s advice. Program staff have
also noted that seeing the patient and his or her living environment (including aspects that
the patient might not tell staff about on the telephone) greatly enhances their ability to
understand the patient’s situation and tailor the intervention to it. 4
4
Mathematica Policy Research, Inc Report to Congress on the Evaluation of the Medicare
Coordinated Care Demonstration, January 3, 2008
4
Recommendations
As the state prepares to move forward with seeking practices to volunteer to reconfigure towards a
PCMH, home health agencies can:
1. Become familiar with the model and support and seek partnerships with physician practices
considering the potential value on converting to a PCMH
2. Work with health centers and practices to alert them to agency resources and specialty skills
that PCMHs may need (e.g., on staff certified diabetes educators, patient self management
coaches, medication reconciliation expertise, falls prevention programs, telehealth)
3. Consider the construct of the financial relationship between and agency and a PCMH to
provide necessary services that practices may be required to either “embed” or contract for,
such as case management, care coordination
4. Explore and operationalize web-based physician communication practices through electronic
health records, physician portals etc
5. Be prepared to demonstrate use of evidence based practice guidelines and outcomes
August, 2009
5