For many doctors and health care experts, the future of medicine lies in transforming primary care practices into something else entirely: centers where every patient’s care is team-based, preventive and comprehensive.
But a new study published this month found that converting traditional practices into the newer model — patient-centered medical homes — creates a host of challenges. Some are logistical, like putting in place the extensive technology needed to make the centers effective. Other problems are more intangible, like trying to require doctors and other medical staff to give up their old roles of treating individual patients in private, one-on-one encounters and instead working within more collaborative teams.
The new study, published in the current issue of the journal Health Affairs, based its findings on data from the National Demonstration Project, the first large-scale experiment with patient-centered medical homes. As part of the project, 36 family practices across the country were recruited and turned into patient-centered practices.
To do this, the practices installed electronic record-keeping and expanded patient access with longer hours and open scheduling. They also began incorporating preventive care, rather than treating just single episodes of illness, into a broader approach. And patients were no longer treated by just one doctor, but by teams of nurses, doctors and assistants who worked together.
Adopting this patient-centered approach, supporters say, has two major benefits: improving the quality of care and reining in health care costs.
But one of the biggest hurdles is time. The transition to a new model can take years and requires outside assistance from management and health care consultants.
The national demonstration project was carried out over two years, and while most of the 36 practices made progress toward becoming medical homes, the two years was not enough time for them to finish, said Dr. Paul A. Nutting, lead author of the Health Affairs study and a professor of family medicine at the University of Colorado Health Sciences Center in Denver. The lag time was particularly surprising because the practices were chosen for the project in part because they were so “highly motivated,” he added.
Part of the problem was that the practices tried to make the conversion in incremental steps, checking things off a list as they went along. But each new change had the potential to create other problems downstream, Dr. Nutting said, especially when it came to technological upgrades.
“Let’s say you implement an electronic medical record,” he said. “That changes the way you work. That affects the people who manage the medical records. You get that in place, you get the work flow arranged for that, and then you say ‘O.K., now we’re going to use that medical record to create a disease registry.’ Now that disrupts things that you already had smoothed out. As you do new things it means you have to go back and change something you already changed to reach kind of a new level of balance or work flow. Often that shows up because somebody’s job gets harder.”
But that was only the beginning of the issues Dr. Nutting and his colleagues uncovered. Many of the practices started out well as they moved toward becoming medical homes, but eventually encountered what the report called change fatigue, defined as that “which was manifested as faltering progress, unresolved tension and conflict, burnout and turnover, and both passive and active resistance to further change.”
Taking on electronic prescribing, patient portals and other technological advancements “proved more difficult than originally envisioned because the health information technology currently marketed to primary care practices resembles a jumble of jigsaw pieces rather than components of an integrated and interoperable system.”
And on a larger scale, to truly improve health care for patients, successful medical homes will have to evolve to become part of medical “neighborhoods,” where hospitals, nursing homes, and specialists collaborate and share information about their patients, the report found. Dr. Nutting stated as an example the gap between primary care and mental health treatment, which usually exist separate from one another, causing problems for patients. Often, he said, “it’s up to the patient to tell their primary care doctor what their psychiatrist is doing or prescribing and vice versa.”
“The ability of primary care and mental health professionals to kind of talk to each other and share care of patients is very, very difficult,” he said. “I hear patients say my primary care doctor and psychiatrist never talk to each other.”
Primary care, the report said, has to be integrated not just with mental health care but other aspects of the medical system. Creating medical homes and then plopping them back into a broken medical system is not going to help very much, Dr. Nutting said. “Health care right now is completely disconnected,” he added.
Over all, the report was optimistic on the future of medical homes, pointing out that the national demonstration project showed that practices that were motivated enough could put in place many of the components of a medical home – albeit with some difficulty – in a “relatively brief” time frame of two years.
But to be successful, the report found, practices will need — perhaps more than anything — “a nurturing policy environment that sets reasonable expectations and time frames,” integration into health care neighborhoods, and at least three to five years of external assistance as they make the changes to become medical homes.
