Support and Strategies for Change Among Small Patient-Centered Medical Home Practices

In 1891 Sir Luke Fildes painted an enduring image of a physician in deep contemplation at the bedside of a mortally ill child in a fisherman's cottage. In 2008, I speculated in an invited Commonwealth Fund commentary on the nascent medical home movement that small practice primary care might also be mortally wounded due to limited capabilities imposed by its size, structure and internal organization. I said in part "...Most small practices today lack the people, process and technology infrastructure, space, capital, and purchasing efficiency to meet the full set of medical home requirements. Meeting medical home requirements may well enhance the pressure on small practices to consolidate or to seek new models for pooling resources to make needed investments in staff and technology; implement process changes; measure, monitor, and improve quality, and create efficiencies to manage unit costs..."1 Small medical practices including primary care are declining, but still represent slightly more than two thirds of all practices by size according to the most recent National Ambulatory Care Survey. Small practices are remarkably resilient and as Sarah Hudson Scholle and colleagues report, are driven by passion for better patient care and patient experiences to adopt the sanctioned medical home model. It is not easy. Indeed, it's really really hard. Need it be so?

Perhaps a part of the hardship small practices seeking to adopt the medical home model have is due to its "outside in" design, namely that it seeks to bring in tools and processes that were developed outside the context of small practices and remodels these to fit them. Clearly, there are many practices that have overcome these challenges and successfully transformed. But there are many more still that have not tried or may not succeed. Here also Scholle et al provide valuable insight into the barriers these practices face with current medical home approaches. Perhaps if innovation for practice transformation was focused specifically on the small practice end users and their context, different approaches would emerge that are more context friendly for strengthening the essential functions of primary care within them, i.e. first contact and continuous, comprehensive, coordinated, patient-focused and community based--B. Starfield. Different methods and tools designed, produced, deployed and improved from inside small practices rather than from frameworks and constructs created externally might be needed for accelerating small practice transformation.

Sarah Hudson Scholle and her superb collaborators remind us yet again that there are fundamental issues and formidable barriers with a construct for better patient care that was not developed or designed with small practice end user requirements in mind. Medical home as currently codified is extremely valuable when applied in the right settings and contexts. Essential primary care functions are what matter and small practices may need alternative approaches to executing these functions better. Innovation is needed that whiteboards how better to perform essential primary care functions from the inside out for small primary care practices.

1 The Medical Home, Round Two: Building on a Solid Foundation. CWF. April 21, 2008

Competing interests:   None declared