There is a clear consensus that primary care needs to be at the center of a reformed US health care system. The Patient-centered Medical Home (PCMH) has emerged as the key strategy for the redesign of primary care. The PCMH model builds upon the core concepts of primary care that include accessible, accountable, coordinated, comprehensive, and continuous care in a healing physician-patient relationship over time. Added to these basic primary care concepts are features that improve quality of care, improve patient centeredness, organize care across teams, and reform the payment system to support this enhanced model of primary care.
Although the core principles of the PCMH were adopted by the major primary care associations in 2007 and endorsed by more than 500 other organizations since, questions remain about how to make the PCMH a reality in current primary care practices. The core principles of the PCMH serve as a general guide, but do not necessarily specify the required capabilities of PCMH practices, the optimal reimbursement strategy, or the ideal methods for facilitating the transformation of current practices to meet the ideals of the PCMH model of care. Thus, although the implementation of the PCMH should be grounded in an evidence base supported by scientific research, new research must accompany policy development so as to inform the optimal implementation of the PCMH, and track the effects of the PCMH on care delivery.
Recently, the Society of Teachers of Family Medicine (STFM) and other family medicine organizations collaborated with parallel organizations in general internal medicine (led by the Society of General Internal Medicine) and general pediatrics (led by the Academic Pediatric Association) in a process to help move this research agenda forward. The centerpiece of this effort was a conference that took place in Washington, DC, on July 28–29, 2009, with funding from the Agency for Health Care Research and Quality (AHRQ), the Commonwealth Fund and the American Board of Internal Medicine Foundation. It brought together over 150 invited experts in primary care, health services, and implementation research; health systems, health insurance, and health policy, as well as patient and family advocates, to develop a policy-relevant research agenda for the PCMH.
The project was notable for several reasons. First, it represents what we hope will be the first of many substantive collaborations with our counterpart organizations in general internal medicine and pediatrics. Each of these organizations represents primary care physicians who share many of the same goals of family physicians and experience many of the same challenges in the current practice environment. Such collaborations can leverage the strength of the 3 specialties to increase the voice of primary care in policy discussions at the national level.
Second, through a series of 6 commissioned papers exploring implementation challenges to various aspects of the PCMH model and small group sessions, the conference served to identify key gaps in our understanding that will need to be filled as we move forward promoting and implementing the PCMH. These papers included the following topics (listed with their senior authors):
Current Landscape of PCMH Demonstrations (Asaf Bitton, MD and Bruce Landon, MD, MBA)
Defining and Measuring the PCMH (Kurt Stange, MD, PhD)
Clinical, Quality of Care, and Satisfaction Outcomes of the PCMH (Diane Rittenhouse, MD, MPH)
Financing and Payment Models for the PCMH (Robert Berenson, MD and Eugene Rich, MD)
Transforming Practice (Charles Homer, MD, MPH and Richard Baron, MD)
The Medical Neighborhood (Mai Pham, MD, MPH)
These papers were presented by their first authors, followed by reactor presentations. Small-group discussions then produced a list of prioritized research questions around each topic. This list of questions was discussed by a panel of expert policy makers to help make the questions most relevant to health policy and health care reform. This panel, moderated by Paul Ginsburg from the Center for Studying Health Systems Change, included AHRQ Director Carolyn Clancy and economist Gail Wilensky as well as representatives from Congressional Staff and the Medicare Payment Advisory Commission (MedPAC).
The primary goal of the conference was to develop a research agenda around the PCMH. Over 40 important questions were identified that could be important to informing policy and promoting the transformation of struggling generalist practices into high performing, patient-centered primary care. Our authors are still working on synthesizing the feedback and prioritizing the questions. But a few examples include the following:
What are the effects of using different definitions of the PCMH?
What are the best measures that will be reflective of impact at the level of the practice and the community?
What form should PCMH-based reimbursement incentives take, and how should these incentives be used for small practice settings?
What form of support is most effective in promoting and sustaining practice transformation?
How does the PCMH fit into the rest of the health care system?
The 6 key papers outlining the research agenda will be published in a special section of an upcoming issue of the Journal of General Internal Medicine. And we anticipate the sponsors of this process will be considering these findings as they establish future research priorities.
But these papers and the conference are only steps in the larger process of helping to make the PCMH a reality. As these agendas are developed, it is essential for family medicine and our primary care colleagues to continue to be key leaders in this process. This will require engagement of academic family medicine organizations such as the Society of Teachers of Family Medicine (STFM), the North American Primary Care Research Group (NAPCRG), and the Council of Academic Family Medicine (CAFM). These organizations can work with AHRQ and with our colleagues in academic general internal medicine and academic pediatrics on developing a funded research agenda for the questions. More importantly, these academic organizations must work with our specialty organizations such as the American Academy of Family Physicians, to help determine how to make the PCMH a reality in clinical practice. This requires the involvement of practicing physicians to help determine which questions are most important to answer to assist in the development of PCMHs. It requires dissemination of these answers to practicing physicians as this new knowledge is generated. It requires engagment with patients and families to ensure that the model is truly patient-centered and family-centered. And it requires collaboration with payers and policy makers to implement payment policies that can support the PCMH model.
This collaborative project of the primary care organizations reflects one step in generating and disseminating the knowledge needed to help make the PCMH a reality.