Dr. Houde is Professor and Associate Dean, School of Health and Environment, Dr. Melillo is Professor and Chair, Department of Nursing, and Dr. Holmes is Adjunct Faculty, School of Health and Environment, Department of Community Health and Sustainability, University of Massachusetts Lowell, Lowell, Massachusetts.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Susan Crocker Houde, PhD, ANP-BC, Professor and Associate Dean, School of Health and Environment, University of Massachusetts Lowell, 3 Solomont Way, Lowell, MA 01854; e-mail: email@example.com.
In the past decade, a renewed interest has emerged in team-based primary care (Grumbach & Bodenheimer, 2004). A number of factors have contributed to this resurgence. The aging of the U.S. population has led to a subpopulation of older adults with multiple chronic conditions. The complexities of caring for this group have made team-based care a necessity. It takes more than the primary care provider’s knowledge, skills, and time to carry out the tasks required to provide appropriate comprehensive care for this older population. A division of labor using a team approach makes it possible to use individual efforts more systematically and take advantage of different talents and skills (Cohen & Fink, 2000).
In a report focused on quality of health care delivery published by the Institute of Medicine (IOM, 2001), a call was made for the creation of a new system of health care delivery with a fundamental shift focusing on changes in the “personal health care delivery system.” Specifically, it called for changes in preventive, acute, chronic, and end-of-life care for individuals. Changes were specified, such as customization based on patient needs and values and viewing the patient as a source of control, which are elements of the patient-centered medical home (PCMH) model.
Background of the Patient-Centered Medical Home
The concept of medical home was first used by the American Academy of Pediatrics (AAP) in 1967. The medical home was introduced as a way to improve the care of children with special health care needs (Carrier, Gourevitch, & Shah, 2009). The American Academy of Family Physicians (AAFP) embraced the model in its 2004 Future of Family Medicine project (Kahn, 2004), and the American College of Physicians (ACP) issued a primary care medical home report in 2006. They added an operational definition that lists three dozen specific activities that should occur within a medical home (Berenson et al., 2008).
The AAP, AAFP, ACP, and American Osteopathic Association (AOA) (2007) developed seven joint principles to define the PCMH:
- Personal physician: Each patient should have an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.
- Physician-directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
- Whole-person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.
- Coordinated and/or integrated care: Care across all elements of the health care system (e.g., subspecialty, hospital, home health, nursing home) and across the patient’s community is facilitated through the use of registries, health information systems, and other means to assure that patients receive the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
- Quality and safety: These hallmarks of the medical home include a robust partnership between the physician and the patient, evidence-based medicine and clinical decision-support tools, accountability for continuous quality improvement, and active participation on the part of the patient and the family.
- Enhanced access: Care should be available through systems such as open scheduling, expanded hours, and new communication options between the patient and health care professionals.
- Payment reform: There should be recognition that the added value provided to the patient will require drastic changes to the current predominant fee-for-service payment system.
It is clear that the seven joint principles of the PCMH have relevance to the care of older adults and to care provided by nurse practitioners (NPs). As both a member of the interdisciplinary team and as the NP-leader of the PCMH, NPs have the potential to make a significant impact in PCMHs and to positively affect patient outcomes. President Obama’s health care reform, The Patient Protection and Affordable Care Act (2010), includes funding to strengthen the primary health care workforce, including establishing new NP-led primary care clinics. Certainly, research has demonstrated the value of NPs in meeting quality care outcomes. In fact, the American Academy of Nurse Practitioners (AANP, 2011) reported that “published literature uniformly shows that nurse practitioners provide care that is high quality, cost effective and equal to or better than the same care provided by physicians” (p. 2).
NPs prepared with practice doctorates (DNPs) have additional education in leadership, health information systems, health care financing, and quality improvement. Thus, they are strongly prepared to assume leadership roles in the PCMH model of care, as defined by the AAP, AAFP, ACP, and AOA (2007, 2009). Only recently have organizations/agencies identified NPs as potentially leading a PCMH. In a joint statement on NPs in patient-centered medical home demonstration projects, the AAFP, AAP, ACP, and AOA (2009) noted that physicians and NPs “share a commitment to ensuring coordinated, comprehensive care for our patients that is driven by improved patient outcomes” (para. 3) and that in the PCMH model, care of patients is “best served by a multidisciplinary team where the clinical team is led by a physician” (para. 7), although these organizations agreed that PCMH demonstration projects “evaluate the effectiveness of nurse practitioner practices seeking designation as a PCMH” (para. 7).
A further definition of a set of 16 activities that comprise a medical home was developed in 2011, many of which have been traditionally nursing roles in health care (Table).
Table: Definition of a Medical Home
Patient-Centered Medical Home Issues
Along with payment and structural concerns in the U.S. health system, operational and cultural issues must also be addressed in the medical implementation of the PCMH model. Even the apparently successful program at Group Health Cooperative of Puget Sound has had its problems (Meyer, 2010). Leaders of the system reported that they have discharged several physicians and staff for failing to make the transition to the PCMH model. Group Health’s medical director says the challenge is to get physicians to work differently. Transitioning to the PCMH may be less problematic for gerontological nurses and NPs who have had experience in caring for older adults using a team-based holistic approach to care. According to Bohmer (2009), physicians currently do not have the managerial expertise to run the new models of care proposed. Acquisition of new knowledge by physicians will be necessary (Bohmer & Lee, 2009). One could argue that NPs—and especially DNPs—have the knowledge and skill base appropriate to be leaders in the newly proposed PCMHs.
The Urban Institute published Will the Patient-Centered Medical Home Transform the Delivery of Health Care? Timely Analysis of Immediate Health Policy Issues (Berenson, Devers, & Burton, 2011), in which they note the controversy surrounding accreditation organization language (e.g., Accreditation Association for Ambulatory Health Care, Utilization Review Accreditation Committee) that requires a physician to lead the medical home, as opposed to a NP when allowed by state scope of practice regulations. Alternatively, the Joint Commission’s Primary Care Medical Home Option, Agency for Healthcare Research and Quality, and the National Committee for Quality Assurance do not require physicians to lead medical homes and instead speak of the primary care clinician: “This term and its provider neutral definition mirrors an important core value of the American College of Nurse Practitioners: Interdisciplinary non-hierarchical team care is the highest quality of care” (ACNP, 2011, para. 1).
The Nurse Practitioner and Patient-Centered Medical Homes
As noted by The Joint Commission (2011):
Primary care clinicians have the educational background and broad-based knowledge and experience necessary to handle most medical and other health care needs of the patients who have selected them, including resolving conflicting recommendations for care. The primary care clinician works collaboratively with an interdisciplinary team and in partnership with the patient to address the patient’s primary health care needs. The primary care clinician is selected by the patient and serves as the primary point of contact for the patient and family. A primary care clinician operating within the primary care home is a doctor of medicine or doctor of osteopathy, advanced practice nurse, or physician assistant.
This definition facilitates access to primary care services provided by advanced practice nurses (APNs) and allows nurse-managed health centers to be eligible to become PCMHs (ACNP, 2011).
The IOM (2011) report The Future of Nursing: Leading Change, Advancing Health specifically recognized the need to have nurses practice to the full extent of their education and training. Particularly, the IOM action steps include removing scope of practice barriers that inhibit APNs from practicing to their full extent in primary care roles. With health care reform, accountable care organizations, and the potential impact on quality and cost savings of PCMHs, APNs should figure prominently in demonstration projects and evaluations of PCMH effectiveness. Currently, the Centers for Medicare & Medicaid Services (CMS, 2011) is testing the PCMH model in the Multi-Payer Advanced Primary Care Practice Demonstration, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration, and under the CMS Innovation Center (CMS, 2011).
Furthermore, the Fellows of the American Academy of Nurse Practitioners (2007) noted that:
In order to reflect the compliment of primary care that is provided nation-wide, it is critical that a patient-centered care model be inclusive of all state licensed primary care providers. Nurse practitioners (NPs) are high quality providers who practice in primary care, ambulatory, acute care, specialty care, and long-term care. In addition to diagnosing and managing acute episodic and chronic illnesses, they emphasize health promotion and disease prevention in their practice. For over 40 years, these expert primary care clinicians have been providing high-quality, cost-effective health care services in health care delivery models that pre-date the “medical home model.”
In fact, in one of the first textbooks for gerontological nurse practitioners, Primary Health Care of the Older Adult (Futrell, Brovender, McKinnon-Mullett, & Brower, 1980), many of the role functions long attributed to NPs in providing primary care to older adults—that of direct provider of health services; independent practitioner; educator of clients, families, community, and self; researcher; consultant in gerontological nursing; collaborator with other health professionals and community agencies; role model for other nurses; advocate for the older individual and the aging population; health planner and potential social policy maker for services and resources needed by older adults; administrator of health agencies rendering service to older adults; and counselor—lend support for why NPs as leaders of PCMHs would effectively meet the proposed goals.
Relative to older Medicare beneficiaries, it is well known that with increased age comes greater risk for chronic disease, often complicated further by multiple chronic illnesses to be managed simultaneously. A highly qualified and knowledgeable health care workforce, including APNs, is essential to handle this challenge as the Baby Boomer population has begun to reach age 65 in 2011 (IOM, 2011). NP-led PCMHs that incorporate primary care with a focus on the prevention of illness and disability will help older adults remain independent as long as possible. Strategic areas for improving the health and quality of life of older adults include preventive services, better screening for and treatment of depression, assistance to help the caregivers of older adults maintain their health and well-being, and addressing end-of-life issues and promoting advanced care planning (Centers for Diseases Control and Prevention, 2011).
Involvement of NPs in demonstration projects and in the search for funding for innovative models of PCMHs led by NPs will advance the primary health care of older adults. Advocacy for inclusion in policies related to PCMHs and informing legislators about successes and potential contributions of NPs in PCMHs are important leadership roles for NPs.
NPs prepared through master’s degree, advanced certificate, and DNP programs are well suited to provide enhanced primary care for older adults to address these needs. NPs promote older adult health and early detection of common syndromes likely to occur in this population. This is done in collaboration with the patient, family, and the health care team to ensure comprehensive health care for the older adult and fully supports the goals of PCMHs. NP-led PCMHs have the potential to facilitate increased access to and provision of high-quality, cost-effective primary care to Medicare beneficiaries. There continues to be a need for further policy refinement to facilitate the leadership role of NPs within PCMHs.
- American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association. (2007, February). Joint principles of the patient-centered medical home. Retrieved from http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.dat/022107medicalhome.pdf
- American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association. (2009, April). Joint statement on nurse practitioners in patient-centered medical home demonstration projects. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/opinion/20090429opin-nps-med-homes.html
- American Academy of Nurse Practitioners. (2011, June). AANP comments on the IOM report, The future of nursing: Leading change, advancing health. Retrieved from http://aanp.org/AANPCMS2/publicpages/AANPIOMResponse92Date8_4_11.pdf
- American College of Nurse Practitioners. (2011). APRNs included in Joint Commission definition of primary care clinician. Retrieved from http://www.acnpweb.org/i4a/pages/index.cfm?pageid=1
- American College of Physicians. (2006). The advanced medical home: A patient-centered, physician-guided, model of health care. Retrieved from http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdf
- Berenson, R.A., Devers, K.J. & Burton, R.A. (2011). Will the patient-centered medical home transform the delivery of health care? Timely analysis of immediate health policy issues. Retrieved from the Robert Wood Johnson Foundation website: http://www.rwjf.org/files/research/20110805quickstrikepaper.pdf
- Berenson, R.A., Hammons, T., Gans, D.N., Zuckerman, S., Merrell, K., Underwood, W.S. & Williams, A.F. (2008). A house is not a home: Keeping patients at the center of practice redesign. Health Affairs, 27, 1219–1230. doi:10.1377/hlthaff.27.5.1219 [CrossRef]
- Bohmer, R.M.J. (2009). Designing care: Aligning the nature and management of health care. Cambridge, MA: Harvard Business Press.
- Bohmer, R.M.J. & Lee, T.H. (2009). The shifting mission of health care delivery organizations. New England Journal of Medicine, 361, 551–553. doi:10.1056/NEJMp0903406 [CrossRef]
- Carrier, E., Gourevitch, M.N. & Shah, N.R. (2009). Medical homes: Challenges in translating theory into practice. Medical Care, 47, 714–722. doi:10.1097/MLR.0b013e3181a469b0 [CrossRef]
- Centers for Disease Control and Prevention. (2011). Healthy aging: Helping people to live long and productive lives and enjoy a good quality of life. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/aag/aging.htm
- Centers for Medicare & Medicaid Services. (2011). Federally qualified health center advanced primary care practice demonstration: Demonstration design. Retrieved from http://innovations.cms.gov/documents/pdf/1_WEB_DemoDescription_v7_newedits_083011.pdf
- Cohen, A.R. & Fink, S.L. (2000). Effective behavior in organizations: Cases, concepts, and student experiences (7th ed.). New York: McGraw-Hill/Irwin.
- Fellows of the American Academy of Nurse Practitioners. (2007). Nurse practitioners: Promoting access to coordinated primary care. Retrieved from http://www.aanp.org/NR/rdonlyres/26598BA6-A2DF-4902-A700-64806CE083B9/0/PromotingAccesstoCoordinatedPrimaryCare62008withL.pdf
- Futrell, M., Brovender, S., McKinnon-Mullett, E. & Brower, H. (1980). Primary health care of the older adult. North Scituate, MA: Duxbury Press.
- Grumbach, K. & Bodenheimer, T. (2004). Can health care teams improve primary care practice?Journal of the American Medical Association, 291, 1246–1251. doi:10.1001/jama.291.10.1246 [CrossRef]
- Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from the National Academies Press website: http://www.nap.edu/html/quality_chasm/reportbrief.pdf
- Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Retrieved from the National Academies Press website: http://www.nap.edu/catalog/12956.html
- The Joint Commission. (2011). Approved standards and EPs for The Joint Commission Primary Care Medical Home option. Ambulatory care accreditation program. Retrieved from http://www.jointcommission.org/assets/1/18/Primary_Care_Home_Posting_Report_20110519.pdf
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- Meyer, H. (2010). Group health’s move to the medical home: For doctors, it’s often a hard journey. Health Affairs, 29, 844–851. doi:10.1377/hlthaff.2010.0345 [CrossRef]
- The Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 148 (2010).
Definition of a Medical Home
|Practices that engage in the following set of activities are a medical home:|
Enhanced access to care
C are continuity
Practice-based team care
Health information technology
Shared decision making
Quality measurement and improvement
New payment systems