Building Patient-Centered Medical Homes and Neighborhoods
Tom McGann, M.D. | 03.21.14
I believe many people by now have heard the term Patient-Centered Medical Home (PCMH) and also the Patient-Centered Medical Neighborhood (PCMN). I also believe many people are likely uncertain of what these concepts really mean. Let me try to illustrate this, not by definition, but rather by an example. Here is a rather common one:
Mary is a patient at a family medicine practice. She has diabetes and hypertension. The physician practice is her patient-centered medical home, where she can rely on the staff and providers to know her, expertly treat her diabetes and hypertension, and counsel her on wellness issues such as nutrition, weight loss, exercise and smoking cessation. It is also the place Mary goes for her immunizations, her aches and pains, and her allergies. She forms a very strong relationship with clinicians, becomes engaged as a partner in her care, her medical home is the place that coordinates all of her health-related needs and together they work to set her goals.
Now, some other things have developed impacting Mary’s health. Two years ago, she suffered a heart attack, was hospitalized and required stenting of her coronary arteries. Unfortunately, this year she has learned she has Multiple Sclerosis and she has also struggled with depression. In addition to the providers at her patient-centered medical home, she now also has providers in cardiology, neurology and behavioral health.
This is where the patient-centered medical neighborhood concept comes in. These new services, from Mary’s perspective, need to be aligned around her. She needs to know that all of the providers caring for her are coordinating her care, not just around their specific services, but all of her care. She expects that treatments and medications and changes in plans are all known to all of her caregivers, and that her Multiple Sclerosis drugs that may interact with her depression are well coordinated and communicated. When she arrives to see any of these providers, she sees that they are fully aware of everything that is going on with her health. Imagine the comfort she feels when one of her consultants says, “Mary, I’ve been in contact with your Multiple Sclerosis doctor and your primary care physician and we are all in agreement with the next steps.” All of Mary’s providers understand her shared care plan that she has developed with the support of her health coach—specifically her desire to be well enough to participate in the planning of her daughter’s upcoming wedding and her ongoing need for physical therapy.
Achieving this PCMH/PCMN environment for all patients is not an easy task. But, imagine you are Mary, or her husband, or her daughter. It is what you would need and expect. Our goal as care providers is to make this happen for our patients.
Another feature of the neighborhood is looking out for each other and helping out. In a good neighborhood, you would expect any of your neighbors to intervene if they saw one of your children lost in the neighborhood. Likewise, all teams in the medical neighborhood should look out for patients who may be in danger, such as having undiagnosed high blood pressure. The hope is that anywhere they “touch” in the medical neighborhood this condition would be discovered and referred to a patient-centered medical home.
Behind the scenes there is much discussion and work occurring between patient-centered medical homes and the patient-centered medical neighborhood. Please support these interactions when they come to your neighborhood.
President, WellSpan Medical Group
Senior Vice President, WellSpan Health