The patient-centered medical home practice model "holds promise" for improving patient and staff experiences, but there's not yet enough evidence to determine how the model affects clinical outcomes and costs, a new report concludes.
In a study funded by HHS' Agency for Healthcare Research and Quality, researchers from the Durham Veterans Affairs Medical Center and Duke University School of Medicine, both in Durham, N.C., looked at 19 previously published studies that included a comparison group. The researchers identified individual medical-home interventions, analyzed financial models and implementation strategies, and evaluated the medical-home model's effects on patient and staff experiences, care processes, and clinical and economic outcomes. Their report is posted on the Annals of Internal Medicine website
The authors defined a medical home as a practice that used team-based care; incorporated at least two of four care-improvement-focused elements such as enhanced care access, care coordination and a systems-based approach to improving quality and safety; represented "a sustained partnership"; and featured "an intervention that involves structural changes to the traditional practice."
The authors noted that their study was "challenging because of a lack of consistent definitions and nomenclature
" for medical homes.
"Moderately strong evidence suggests that the medical home has a small positive effect on patient experiences and small to moderate positive effects on preventive care services," the authors wrote. They added that there was some evidence that staff experience "improved by a small to moderate degree," but noted that no study reported the medical home's effect on staff retention.
The authors said the reports studied suggested that the medical home model resulted in fewer emergency-department visits but not in hospital admissions for older adults. They added, "There was no evidence for overall cost savings."
The report also noted that most medical-home studies focus on older adults who have multiple chronic conditions, and few look at general adult or pediatric populations—event though the American Academy of Pediatrics is credited with first developing the medical-home concept in 1967.
The researchers found weak or little evidence suggesting savings in total costs or decreased emergency-room visits and inpatient service utilization, but cited a study of the Geisinger Health System that suggested "savings may occur with lengthy exposure to the PCMH system of greater than one year."A study
published in the January/February 2012 issue of the American Academy of Family Physicians' journal, the Annals of Family of Medicine, also reported that payment reforms such as "additional practice reimbursement for time spent coordinating care and integration of care coordinators with primary-care teams" were required—particularly for small practices—"to deliver optimal care to patients with complex care needs."
Before selecting the studies to be analyzed, the researchers identified 5,731 studies referencing patient-centered medical homes. Of those, 768 passed "abstract screening," 60 passed "full-text screening," and only 19 contained the data on effectiveness that the authors were looking for. The AHRQ has suggested a weakness in medical-home research before.
Last December, AHRQ released a brief
offering suggestions on how to improve medical home research
More recent studies have shown that the medical home model can reduce emergency-department visits
and hospitalizations for patients with chronic disease and improve care for diabetics
In June, a medical home demonstration
by Blue Cross and Blue Shield plans in Maryland, Virginia and Washington, D.C., reported savings of 1.5%—an outcome described as "very substantial," given the plans' $2.5 billion in claims paid for 2011.