Organizing Care for Complex Patients in the Patient-Centered Medical Home

The Article in Brief

Organizing Care for Complex Patients in the Patient-Centered Medical Home

Eugene C. Rich , and colleagues

Background The Agency for Healthcare Research & Quality and Mathematica Policy Research offer a summary report of strategies to help smaller primary care practices transform into medical homes that effectively serve patients with complex needs, particularly the frail elderly and working-age adults with disabilities.

What This Study Found Drawing on case studies of 5 programs around the United States that use a variety of approaches for supporting and collaborating with smaller, independent primary care practices in caring for patients with complex needs, the summary concludes that small practices require support and resources beyond those needed to meet current medical home standards. The two most critical supports are additional practice reimbursement for time spent coordinating care and the integration of care coordinators within primary care teams. The summary includes a link to a longer policy brief published simultaneously on the AHRQ Web site.

Implications

• Patients with complex health care needs represent the greatest challenge to transforming small primary care practices into high-functioning medical homes. They also present a great opportunity to improve such outcomes as lower costs, higher quality, and better care experiences for patients and clinicians.