Wednesday May 15, 2013

Relationships Are a Critical Part of Building Medical Homes

The small Nebraska town where I practice family medicine has a population of about 2,000. Although my practice is only 30 minutes west of Lincoln -- the state's capital and second-largest city -- solo and small family practices are common in the rural areas to my north, south and west.

As my colleagues in these small practices ponder the patient-centered medical home (PCMH), I know that it can seem overwhelming to implement. The bodies that recognize or certify PCMH practices have numerous confusing requirements that have more to do with processes than patient care. So when I talk to family physicians who have concerns about the PCMH, I suggest they read the original articles on the subject by Barbara Starfield, M.D., M.P.H.

Instead of a large number of boxes to check, Starfield thought there were three simple things at the core of becoming a medical home.

The first is to be comprehensive in your approach to health care. It is comprehensiveness that separates us from our subspecialty colleagues who focus on a single organ system or a single disease entity. It is comprehensiveness that separates us from midlevel providers who say they can deliver care as well or better than family physicians. Ordering more tests and referring to subspecialists is not comprehensive care. Family medicine is.

The second critical factor is disease management. We all know there are certain diagnoses that predispose patients to increased morbidity and mortality. The Academy has clinical recommendations and resources to help your practice with chronic disease management protocols that fit your practice. You also can develop disease registries to be more proactive with these patients. By doing so, we can reduce morbidity and mortality and ultimately reduce costs to our health care system.

Finally, relationships and continuity of care are important. Knowing our patients and their families facilitates caring for them. This can reduce duplication of tests and improve compliance to treatment plans by understanding each patient's culture and concerns. I recently had this brought home to me by one of my long-time patients.

Oliver was a 92-year-old, retired minister who had contracted pneumonia and required hospitalization. I have cared for his family for years. In fact, I delivered two of his grandsons.

Oliver was not responding to treatment, so as I examined him, I talked to his family -- including those grandsons -- about other interventions we could try to improve his situation. As I talked, his son, David, got out of his chair, came to me and placed his hand on my arm. He said, "Dr. Wergin, you know my dad loves you, and we all love you. You are as much a part of our family as anyone in this room. We wanted to let you know that my father does not fear death and is ready for what's to come. In fact, we are all ready for what's to come, but we're worried about you. You don't seem to be ready."

I looked at David and told him I understood. I went to the nurse's station and wrote a prescription for morphine and other comfort measures. I continued to round on him and talk to him each day. There was no new hospice nurse or shift-working hospitalist. Instead, it was just me and Oliver's family. That's family medicine.

Oliver passed away a few days later. It was a quiet death, and his family members were with him.

Medicine is always changing, and we have to be prepared. It is important to develop a plan to meet PCMH requirements if you want to be recognized or certified as a PCMH practice. We know that our strict fee-for-service model, which has not served us well, is coming to an end. To be reimbursed in a new model of payment, we must show we deliver what we promise. Don't be discouraged, and remember that patient-centered care is based on these three things: comprehensiveness, disease management and relationships.

How do you build relationships with your patients?

Robert Wergin, M.D., is a member of the AAFP Board of Directors.

Comments:

Well written Bob. It is the reason that I still take care of my inpatients (continuity) and take a deep breath before I refer up the road. It is also the reason many of us are frustrated that it does take "checking lots of boxes" and purchasing the designation to "become a medical home" when we have tried to provide care by those basic principles our entire careers.

Posted by 127.0.0.1 on May 16, 2013 at 09:15 AM CDT #

Thank you. Maybe there is hope for us, after all.

Posted by John Miller on May 16, 2013 at 12:20 PM CDT #

Well done! Remembering what underlies PCMH is so critical as many do not see the forest for the trees when looking to get NCQA recognized. Providing the whole value family medicine can provide has been lost to many. Returning to those values is the goal behing the push toward PCMH. It is easiest done and best done by first truely appreciating the qualiies being sought. If I were to add to what is needed it would be to focus on acchieving these three thinking of the patient first. For me this resembles a selfless giving and nurturing which appeals to higher standards within me even as I am challenged by the call to duty for the day.

Posted by Randall Rickard on May 18, 2013 at 07:13 AM CDT #

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