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Research ArticleOriginal ResearchA

Implications of Reassigning Patients for the Medical Home: A Case Study

Katie Coleman, Robert J. Reid, Eric Johnson, Clarissa Hsu, Tyler R. Ross, Paul Fishman and Eric Larson
The Annals of Family Medicine November 2010, 8 (6) 493-498; DOI: https://doi.org/10.1370/afm.1190
Katie Coleman
MSPH
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Robert J. Reid
MD, PhD
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Eric Johnson
MS
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Clarissa Hsu
PhD
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Tyler R. Ross
MA
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Paul Fishman
PhD
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Eric Larson
MD, MPH
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  • Unique Challenges Implementing the PCMH in Residency Programs
    Katie Coleman
    Published on: 09 December 2010
  • Still a go for PCMH with the FP residency
    Jessamine A Hippensteel
    Published on: 09 December 2010
  • [Author response] Medical Home Improves Primary and Secondary Prevention
    Katie Coleman
    Published on: 18 November 2010
  • PCMH Must Focus on Prevention
    Michelle E Cooke
    Published on: 15 November 2010
  • The Group Health Cooperative Medical Home is a Success Story
    Joseph E Scherger
    Published on: 09 November 2010
  • Published on: (9 December 2010)
    Page navigation anchor for Unique Challenges Implementing the PCMH in Residency Programs
    Unique Challenges Implementing the PCMH in Residency Programs
    • Katie Coleman, Seattle, WA

    Thanks so much for your comment about residency programs. Group Health runs a Family Practice residency program that is implementing the medical home model as part of the system-wide spread. The residency program faces unique challenges when implementing the medical home, especially around issues of continuity. We are looking forward to learning from our residency program about what parts of the model are directly tr...

    Show More

    Thanks so much for your comment about residency programs. Group Health runs a Family Practice residency program that is implementing the medical home model as part of the system-wide spread. The residency program faces unique challenges when implementing the medical home, especially around issues of continuity. We are looking forward to learning from our residency program about what parts of the model are directly translate-able and what need to be customized to suit its teaching mission and structure.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (9 December 2010)
    Page navigation anchor for Still a go for PCMH with the FP residency
    Still a go for PCMH with the FP residency
    • Jessamine A Hippensteel, Fort Wayne, Indiana

    After presenting the article to a large family practice residency and several faculty members, the conclusion was benefits were still better than the possible negative outcomes. When the PCMH model is completely implemented into our program, the implications discussed would likely not affect us. Our patient failure and ED/urgent care utilization is already elevated. Our patients are turned-over every three years or more...

    Show More

    After presenting the article to a large family practice residency and several faculty members, the conclusion was benefits were still better than the possible negative outcomes. When the PCMH model is completely implemented into our program, the implications discussed would likely not affect us. Our patient failure and ED/urgent care utilization is already elevated. Our patients are turned-over every three years or more frequently due to residents graduating the program. There is an inherent graduated scale of patient volume givien the class year, so it would be difficult to have even panels. We truly doubt the care experience scores would be less with reassigned vs current.

    Therefore, any benefit from the PCMH model would only serve to benefit our residency and our patient population. More stream-lined, better care would outweigh the potentional implications that the article discussed.

    Unfortunately for the study, the age of the patients as well as the length of the study made significant limitations. Like previously mentioned, healthier younger patients don't frequent offices or care settings as much as older patients. We feel that the power of the study is greater reduced given the patient population and the tracking length and method of the study.

    Further research regarding implication of PCMH should include populations in the urban, under-served areas of more diverse age groups as well as PCMH that include multi-specialty groups.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (18 November 2010)
    Page navigation anchor for [Author response] Medical Home Improves Primary and Secondary Prevention
    [Author response] Medical Home Improves Primary and Secondary Prevention
    • Katie Coleman, Seattle, WA USA

    Thanks for highlighting the important issue of prevention. We agree that preventive care – in addition to good chronic and acute care - is an essential component of high quality primary care. As part of the medical home demonstration, Group Health aimed to put systems in place to improve care across the whole practice for all patients.

    In fact, two of the components of the intervention – outreach and pre -vi...

    Show More

    Thanks for highlighting the important issue of prevention. We agree that preventive care – in addition to good chronic and acute care - is an essential component of high quality primary care. As part of the medical home demonstration, Group Health aimed to put systems in place to improve care across the whole practice for all patients.

    In fact, two of the components of the intervention – outreach and pre -visit preparation - were targeted directly at patients whose planned care needs were unmet. In our year 1 and year 2 analyses, we found practice- wide improvement on HEDIS measures, including measures of both primary and secondary prevention, across patient populations. Though we did not publish the results of the measures individually, they are included in the quality composite measures outlined here:

    Reid RJ, Fishman PA, Yu O, Ross TR, Tufano JT, Soman MP, et al. Patient-centered medical home demonstration: a prospective, quasi- experimental, before and after evaluation. Am J Manag Care. 2009 Sep;15(9):e71-87.

    And here:

    Reid RJ, Coleman K, Johnson E, Fishman P, Hsu C, Soman MP, Trescott CT, Erikson M, Larson EB (2010). The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health Affairs 29(5):835-843.

    In regards to the patients who were reassigned to different providers as part of the effort to reduce panel size and increase visit length, our results hardly indicate that patients were abandoned. Indeed our study showed no difference in patient experience of care, electronic communication or ED utilization. Perhaps this finding bolsters your point that a re-examination of the meaning of continuity for a young adult population is in order.

    For those practices interested in expanding the time physicians have to interact with their patients as part of the medical home, panel sizes may need to be reduced. The goal is to do that in a way that disrupts care as little as possible. Asking providers to flag those patients for whom continuity is most clinically important may be a way to do just that.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (15 November 2010)
    Page navigation anchor for PCMH Must Focus on Prevention
    PCMH Must Focus on Prevention
    • Michelle E Cooke, Atlanta, USA

    Your November/December 2010 article entitled “Implications of Reassigning Patients for the Medical Home: A Case Study” is a great example of the power and limitations of the Patient Centered Medical Home (PCMH) model. Thus far in the literature, the strengths of the PCMH have been focused on secondary prevention of chronic illnesses such as diabetes and hypertension. While the PCMH shows great promise in more optimal man...

    Show More

    Your November/December 2010 article entitled “Implications of Reassigning Patients for the Medical Home: A Case Study” is a great example of the power and limitations of the Patient Centered Medical Home (PCMH) model. Thus far in the literature, the strengths of the PCMH have been focused on secondary prevention of chronic illnesses such as diabetes and hypertension. While the PCMH shows great promise in more optimal management of chronic illness, the model fails to emphasize the importance of preventive services for healthy patients. Just as this case study demonstrates, younger, healthier patients were more likely to be reassigned to other physicians than their older, sicker counterparts. Intuitively, sicker patients should have priority for health care services, but the PCMH cannot continue to neglect the healthy population. It is within this young, healthy population that the PCMH has the distinct opportunity to showcase the power of primary care – prevention. So far, only one study (Ferrante, March 2010) has examined delivery of preventive services in the PCMH model. The Ferrante study concludes that “Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices…”, but even in this study, the average patient age was 64, and very few patients were under 50 years old.

    Although the case study reveals that the healthy population had decreased use of primary care after reassignment, the decreased use does not necessarily equate to poorer outcomes. We must re-examine what primary care and continuity of care should entail for a young adult population. This healthy population does not require frequent use of primary care, but instead requires effective preventive services such as appropriate screenings and vaccinations. Contrary to the perception that these reassigned patients are low-priority in the healthcare setting, these patients possess the most valued asset in medicine – a clean bill of health. The PCMH must focus more attention on preserving the health of the young population rather than concede to the temptation of abandoning them by reassignment.

    Ferrante J, Balasubramanian B, Hudson S, Crabtree B. Principles of the Patient-Centered Medical Home and Preventive Services Delivery. Ann Fam Med. 2010 March; 8(2): 108–116.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (9 November 2010)
    Page navigation anchor for The Group Health Cooperative Medical Home is a Success Story
    The Group Health Cooperative Medical Home is a Success Story
    • Joseph E Scherger, Rancho Mirage, CA, USA

    The conversion to a medical home at Group Health Cooperative is an impressive success story. The physicians spend 30 minutes in routine office visits and have an hour a day to communicate with patients online and on the telephone. In co-practice with a PA or NP, they manage a panel of 1800 patients. While the costs of the primary care office are increased from the previous model of a larger panel of patients, the syst...

    Show More

    The conversion to a medical home at Group Health Cooperative is an impressive success story. The physicians spend 30 minutes in routine office visits and have an hour a day to communicate with patients online and on the telephone. In co-practice with a PA or NP, they manage a panel of 1800 patients. While the costs of the primary care office are increased from the previous model of a larger panel of patients, the system saved substantial dollars due to improved primary care (fewer hospital based costs and more appropriate referrals).

    This article looks at the patients that needed to be reassigned to other physicians. Overall this did not turn out to be a problem. In an primary care physician panel, there is a group of patients for whom continuity of the relationship is very important, and a group that simply wants convenient care. It is good to see that this natural selection took place at Group Health.

    In our model at Eisenhower Medical Center in California, patients pay a membership fee ($30-50 a month based on age) to keep their primary care physician after a conversion to a Medical Home model. We have found that more patients than expected were willing to pay for better primary care and keep their chosen physician. These patients were similar to the Group Health experience in that they were sicker, older and had a longer relationship with the physician.

    Optimzing the process of primary care through the Medical Home model has been tested in large, medium and small practices, and is ready to spread as the new model of primary care practice.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 8 (6)
The Annals of Family Medicine: 8 (6)
Vol. 8, Issue 6
1 Nov 2010
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Implications of Reassigning Patients for the Medical Home: A Case Study
Katie Coleman, Robert J. Reid, Eric Johnson, Clarissa Hsu, Tyler R. Ross, Paul Fishman, Eric Larson
The Annals of Family Medicine Nov 2010, 8 (6) 493-498; DOI: 10.1370/afm.1190

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Implications of Reassigning Patients for the Medical Home: A Case Study
Katie Coleman, Robert J. Reid, Eric Johnson, Clarissa Hsu, Tyler R. Ross, Paul Fishman, Eric Larson
The Annals of Family Medicine Nov 2010, 8 (6) 493-498; DOI: 10.1370/afm.1190
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