The patient-centered medical home is a term that we have been hearing
with increasing regularity lately. Although the concept has been around since
1967 and was originally applied to coordinated pediatric care, it was recently
expanded to encompass patients in all stages of their lives with many health
Basically, the current medical home concept calls for patient-focused,
personalized care that is coordinated and overseen by a primary care physician.
It is meant to address the inadequacies of the current health care system by
improving the patient-physician relationship and making the primary care
practice environment the centralized location for all of the patient’s
medical needs — including acute, chronic and preventive services. A
medical home also emphasizes enhanced care through electronic medical records,
evidence-based guidelines, open scheduling, expanded hours and better
communication between patients, physicians and staff.
Because the medical home concept is gaining traction in the greater
health care community, it is critical that we explore the opportunities that
arise for health care professionals who deliver care to patients with diabetes.
The American Association of Diabetes Educators has long supported the
team-based approach to diabetes care and asserts that diabetes educators are
important members of the care team who provide evidence-based, patient-centered
care to people with diabetes.
Self-care training and support is essential for the successful outcomes
of patients with diabetes and other chronic illnesses. AADE’s Practice
Advisory, “The Medical Home and Its Importance for the Diabetes
Educator,” contends that educators help physicians implement and carry out
care plans and that it is important that they be included as a key member of
the patient-centered medical home (PCMH) team.
Providing self-care support and community resources is one of the
standards that prospective medical homes must meet to be recognized by the
National Committee for Quality Assurance. Therefore, there is a great
opportunity for diabetes educators to be fully integrated into the everyday
workings of a medical home.
Currently, AADE is exploring the feasibility of incorporating a
multilevel diabetes education team (See chart) into the PCMH model
through a demonstration project. The objectives of the project are to:
- Advocate and achieve full integration of diabetes educators into the
PCMH diabetes care team.
- Demonstrate the effectiveness of a multilevel diabetes
self-management education and training team within the PCMH model.
- Assess economic and operational feasibility, strength and weaknesses
of this type of integration.
- Monitor the clinical, behavioral and utilization results that are
associated with the provision of diabetes self-management education and
training in this context.
Specifically, the demonstration project will include six or seven sites
at different stages of becoming a PCMH. The sites will cover a multitude of
settings, from universities to larger multisite medical centers. A diabetes
educator, who may serve or work at one or more sites/clinics, will be a
designated member of the PCMH team and will be fully integrated into the care
of patients with diabetes. In addition, community health workers will be
included in the team, as well as other health care professionals. Emerging
payment options for medical home services (such as capitation, bundled payments
and fee-for-service) will also be explored during the demonstration project.
The PCMH concept has the potential to greatly extend the effectiveness
of the care provided to patients. It can offer better coordination with
specialty practices and could significantly improve the data-sharing process
among the continuum of care. Many questions remain, however.
It is still unclear whether the medical home has the ability to deliver
the quality care, coordination and reduction of health care costs and
utilization that the advocates of the model are promising. According to the
AADE Practice Advisory on medical homes, some of these concerns are directly
related to whether this can be accomplished in a system with so few PCPs,
physician extenders such as diabetes educators and a lack of technological
resources to allow the medical home model to succeed on a national level.
Despite these reservations, the medical home concept deserves serious
consideration. More research and data are needed to determine whether this is a
sustainable model, and it is, therefore, beneficial to examine how diabetes
educators can fit into the model early-on in its development.
Donna Tomky, MSN, RN, C-NP, CDE, is president of the American
Association of Diabetes Educators.