Achieving Value in Primary Care: The Primary Care Value Model

William Rollow; Peter Cucchiara

doi:10.1370/afm.1893

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Author Response to Dr. Khanna
William C. Rollow, MD MPH

Published on: 14 March 2016
Achieving Value in Primary Care: The Primary Care Value Model
Niharika Khanna

Published on: 10 March 2016

Published on: (14 March 2016)
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Author Response to Dr. Khanna
William C. Rollow, MD MPH, Clinical Director
Dr. Khanna stresses the importance of identifying and addressing social determinants of health (SDH) in value-driven primary care. We advocated for this through the inclusion of "preconditions of health" as a patient-centered value and "mental/social/community integration" as one of the three coordination activities in the value model.
Dr. Khanna notes that experience with this in primary care is limited, as a...
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Dr. Khanna stresses the importance of identifying and addressing social determinants of health (SDH) in value-driven primary care. We advocated for this through the inclusion of "preconditions of health" as a patient-centered value and "mental/social/community integration" as one of the three coordination activities in the value model.
Dr. Khanna notes that experience with this in primary care is limited, as are systems and financial support for it. While we agree that little has been published in this regard, we have had experience with integrated care planning activities under the health home model in New York State. That experience highlights the challenges of incorporating SDH assessment and integration with care planning: (1) Clinicians and care managers do not readily understand how they can help each other support patients in achieving health goals. (2) Under most reimbursement systems, clinicians are paid for patient encounters rather than for interaction with care managers. (3) EHRs generally do not support SDH assessment and care planning.
We view incorporation of SDH assessment and interventions as a critical element in improving the value of primary care for patients of low socioeconomic status. Alongside of this, for patients with chronic illness we advocate for use of measures based on self-reported outcomes, healing, and therapeutic relationship, and clinical care models such as those developing in PCMH and integrative medicine practices.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (10 March 2016)
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Achieving Value in Primary Care: The Primary Care Value Model
Niharika Khanna, Associate Professor and Director Maryland Learning Collaborative
Drs Rollow and Cucchiara have presented a very interesting view of Value Based Models where there is whole person orientation, payments for patient centered care and additionally, payments for integrative medicine and for addressing Social Determinants of Health(SDH). This discussion is timely and sets forth a potential model of care delivery which maybe far ahead of the current state of practice. It is also true that S...
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Drs Rollow and Cucchiara have presented a very interesting view of Value Based Models where there is whole person orientation, payments for patient centered care and additionally, payments for integrative medicine and for addressing Social Determinants of Health(SDH). This discussion is timely and sets forth a potential model of care delivery which maybe far ahead of the current state of practice. It is also true that SDH sensitivity is a critical component of family practice, although there is no systematic method to demonstrate the value of SDH sensitivity at this time.
The science of social determinants providing value to primary care is in its infancy at the present time. The Centers for Medicare and Medicaid Services has initiated a relatively new effort to start to include behavior and social determinants in history sections of Electronic Health Records of the future. Assuming that supportive federal policies ensue regarding inclusion of SDH in EHR, Electronic Health Records vendors will become in alignment with this proposal and we will start to see new sections of the EHR where systematic capture of SDH data can occur. These structural changes in the EHR will provide the tools to extract SDH for population health and for individual patient care, thus creating the beginnings of a process for value based models of care.
This new area of eliciting, documenting and addressing SDH will need additional practice supports to implement and there will be a need for education of practicing physicians in documenting relevance of the SDH to the patients' health and, how they leveraged community resources to address SDH. This documentation must occur in a way that allows extraction of this data for individual care and for population health of the communities served by the practice. After this very critical step is achieved, there will be a process and pathway to inclusion of SDH in value based models of care.
This letter does not include the substantial role other health care stakeholders will need to play to address SDH in patients. The complexity of SDH and the multitude of resources needed to address each SDH maybe the beginnings of a new area of query. There is a need to mobilize leaders, clinicians, academics and others in developing a much greater understanding of the role of SDH, how to elicit and document SDH, and most importantly, how to address SDH in a clinical setting and provide patients with comprehensive health care that is value based. I certainly hope that the STFM community will get behind a process to inclusion of SDH in Value Based Models of Care and, a pathway to placing the family physician at the center of this model.
Competing interests: None declared
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Competing Interests: None declared.