The Health Care Home Model: Primary Health Care Meeting Public Health Goals

Roy Grant; Danielle Greene

doi:10.2105/AJPH.2011.300397

. 2012 Jun;102(6):1096–1103. doi: 10.2105/AJPH.2011.300397

The Health Care Home Model: Primary Health Care Meeting Public Health Goals

Roy Grant ^1,^✉, Danielle Greene ¹

PMCID: PMC3483945 PMID: 22515874

Abstract

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.

THE AMERICAN PUBLIC HEALTH Association (APHA) has 3 overarching policy priorities: rebuild the public health infrastructure, ensure access to care, and reduce health disparities.^1,2 The health care home model contributes to these goals by improving health care delivery at the patient level through redesigning and expanding the scope of primary health care services and improving the interface between primary care practices and public health agencies.

In November 2010, APHA endorsed the health care home model of primary care for its public health value. Health care home, a term used by the National Association of Community Health Centers, is a model also referred to as the medical home.^3,4 The health care home is a vehicle by which patient- and family-level care at the point of delivery may contribute to meeting population-level goals of improving access to care, reducing health disparities, increasing preventive service delivery, and improving chronic disease management.⁵ Here we summarize the APHA health care home policy statement and suggest next steps for moving the model forward.

BACKGROUND

The medical home concept was introduced by the American Academy of Pediatrics in 1967 as a model of primary care for children with special health care needs. It was intended to help coordinate multidisciplinary services from diverse sources to treat children with complex medical conditions and associated developmental problems. The model emphasizes care that is continuous, comprehensive, coordinated, compassionate, family centered, and culturally and linguistically appropriate.^6,7

Although the model originated in pediatrics, it has applicability across the life span. The nature of family-centered care for young dependent children, for whom parents and other caregivers are integral to any treatment plan, differs from health care for adolescents, where patient confidentiality is often critical, or for adults with chronic health conditions. In pediatrics, family-centered care should be age appropriate for the patient; for adults, it should be consistent with patient choice and privacy protection.

Consistent with this transition, the model has often been referred to as the patient-centered medical home. The concept of patient centeredness was identified as an important domain of quality care by the Institute of Medicine in 2001.⁸ The patient-centered medical home was described in 2007 through a Statement of Joint Principles by the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and American Osteopathic Association⁹ and subsequently endorsed by the American Academy of Nurse Practitioners⁸ and American Dietetic Association.¹⁰ It includes the chronic care model of patient self-management for chronic conditions and evidence-based and evidence-informed protocols.^11–13

The enhanced medical home was introduced as a model of care for medically underserved, high-risk populations. Alternative modes of primary care service delivery to improve access to care are emphasized, such as school-based health centers¹⁴ and mobile medical clinics.¹⁵ Clinical efficacy of school-based health centers has been demonstrated by reduced children's health disparities¹⁶ and clinical outcomes of mental health services on par with community clinics.¹⁷ Mobile clinics are effective in providing access for hard-to-reach populations¹⁸ and are associated with significant health system cost savings by preventing hospital and emergency department (ED) use.¹⁹ The enhanced medical home also incorporates electronic health records, facilitated access to specialty care, integration of specialty care services (e.g., mental health and oral health care in the primary care setting), transportation, and case management to enhance care coordination.²⁰

Use of the term health care home helps avoid problems associated with the term medical home, which has been interpreted as limiting implementation of this model to physicians only.²¹ The term health care home makes it clear that this model may be implemented by the full range of primary care providers: diversely specialized physicians (e.g., pediatricians, internists, obstetrics/gynecology specialists, family practitioners, gerontologists, and osteopaths), nurse practitioners and advanced-practice nurses, physician assistants, and others as approved within their states.

ROLE IN PUBLIC HEALTH

Low-income and racial/ethnic minority people have less access than do others to the high quality of care that characterizes the health care home.²² For children, disparities include a significantly lower likelihood of having a usual source of care, a provider that spends enough time and communicates effectively with them,²³ and appropriate management of chronic conditions such as asthma.²⁴

The health care home model attempts to reduce access barriers by providing services such as facilitated enrollment in health insurance, transportation, extended operating hours, and integration of key specialty services at the primary care site, which serves as the locus of care coordination. Colocation of multiple services at the primary care site facilitates same-day appointments with different providers.²⁵

Reducing Health Disparities

Minority and low-income people have higher incidence of chronic conditions and higher rates of morbidity and mortality.²⁶ In addition to alleviating access barriers, the health care home is a cost-effective way to improve health care quality, reduce medical errors, improve outcomes for patients with chronic disease, enhance management of psychosocial problems, and integrate mental health services with primary care, all contributing to the reduction of health disparities.²⁷ A 2008 literature review conducted for the Minnesota Department of Health highlighted multiple studies that reported cost savings attributable to the health care home model through reduced hospital and ED use, lower medication use, and fewer tests. The greatest savings were achieved for patients with chronic and complex health care needs.²⁸

The health care home model contributes to the reduction of disparities in the incidence, severity, and morbidity of ambulatory care sensitive conditions²⁹ and chronic conditions that disproportionately affect poor and minority adults, such as diabetes,³⁰ cardiovascular disease,³¹ and HIV.³² The model improves patients’ receipt of preventive services, such as cancer screening for adults³³ and immunization for children.^34,35 Studies of effective programs for diabetes management show a reduction in hospital use and associated costs³⁶ through implementing components of the model, such as culturally and linguistically relevant patient health education³⁷ and a team approach that includes a clinical nutritionist.³⁸

Meeting Special Health Care Needs

Chronic disease management.

It is estimated that more than half (52%) of working-aged adults have a chronic condition. They account for 4 times the health care expenditures of adults with no chronic care needs.³⁹ Incidence of chronic disease is expected to increase as the population ages.⁴⁰ The health care home model incorporates an expanded role for the primary care provider in the treatment of patients with chronic conditions, potentially reducing the need to see medical specialists.⁴¹ Elements of the chronic care model are integral to the health care home, including support of patient self-management, which improves outcomes for patients with chronic conditions such as diabetes and cardiovascular disease.⁴²

Mental health integration.

The responsibility to treat psychiatric disorders has increasingly shifted to primary care providers, in part because of mental health provider shortages and paltry insurance reimbursement for mental health services, especially for children and youths.^43,44 Adults with depression often do not receive treatment, and most of those treated do not receive care consistent with best-practice guidelines. African Americans and Latinos are especially likely to go without needed mental health services.⁴⁵

Patients with anxiety disorders use more primary care and medical specialty services than do other patients, incurring greater health care costs.⁴⁶ For adults with chronic conditions, depression is associated with greater symptom severity, worse quality of life,⁴⁷ and fewer screenings that might prevent serious complications, such as from diabetes.⁴⁸ Major depression is associated with increased mortality.⁴⁹ Integration of mental health and primary care services, an important element of the health care home model, is associated with improved access to mental health services and better clinical outcomes.^50,51 This may be especially valuable for low-income and minority people with substance abuse disorders.^52–54

Women's health.

Comprehensive and coordinated care are key elements of the health care home model and integral to centers of excellence that have been developed to improve women's health care services.⁵⁵ Women often prioritize the health care needs of family members over their own. The health care home provides opportunities for women to receive health care services through colocated and coordinated systems of care when bringing a child or partner to a medical appointment. This may narrow the gender gap for receipt of preventive services.^56,57 Colocated services and a family-centered approach to service delivery in the health care home also will contribute to reductions in health disparities and improvements in chronic disease management by allowing providers to address diet, nutrition, physical activity, and home environment factors that may contribute to multiple generations suffering from the same conditions, such as obesity, diabetes, asthma, and cardiovascular disease. Intergenerational care—involving multiple generations of her family for whose health a female patient may take responsibility—is associated with improved management of chronic conditions and better health outcomes.⁵⁸

TESTING THE MODEL

Efforts are ongoing to develop criteria to distinguish a health care home from other primary care practices. A Medical Home Index has been developed to assess the degree to which primary care practices are consistent with the model, with ratings derived from a 100-point scale in 6 domains: organization, chronic care management, care coordination, community outreach, data management, and continuous quality improvement activities.⁵⁹ Investigators used this index to assess whether 43 pediatric primary care practices implemented by 7 health insurance plans in 5 states had improved child health outcomes. They found that higher scores on the index were associated with improved outcomes—specifically, fewer hospitalizations and lower rates of ED use.⁶⁰

Many statewide pilot and demonstration projects are under way to test the clinical efficacy of the patient-centered medical home model and to develop an appropriate reimbursement structure for primary care practices that are recognized or accredited as patient-centered medical homes. One focus is fiscal viability and sustainability through innovative reimbursement mechanisms; the goals of a program in Colorado, for example, are to transform primary care and create a more cost-efficient health system. A pilot program in Maine is the first step in a projected statewide implementation of the health care home primary care model. Public and commercial insurers are working toward a payment system that rewards quality, as measured by Institute of Medicine criteria (safe, effective, timely, efficient, equitable, patient centered), with the goal of improving quality while reducing cost. Several projects are focusing on care coordination for patients with chronic conditions, such as a North Dakota pilot project that is following up on preliminary findings that the model saved $520 per member per year, attributable to reduced hospital and ED use.^61,62 A strategic plan has been developed in Pennsylvania to improve chronic disease management and reduce avoidable hospital and ED use and associated costs by improving patient self-management of chronic disease and by use of evidence-based protocols, clinical information systems, and community engagement.⁶³

In pediatrics, states such as Colorado, Illinois, Iowa, Minnesota, Pennsylvania, and Texas are focusing on collaboration among Medicaid, the Children's Health Insurance Program, and maternal and children's health (Title V) programs to improve patient and family-centered child health care and delivery of preventive services. Preventive services under Medicaid's Early Periodic Screening, Diagnosis, and Treatment Program for children include hearing, vision, developmental, and oral health screening⁶⁴ to promote school readiness and improve future health status.⁶⁵

These examples add to the growing evidence that the model improves the quality of patient care and reduces costs by improving clinical outcomes and reducing hospital and ED use.⁶⁶ An extensive literature review revealed that studies consistently document clinical benefits and savings to the health care system from implementation of the health care home model. It is notable that increases in reimbursement for participating primary care practices are far less than the savings they produce. Practices also provide services for which they may receive no reimbursement, such as case management for care coordination and patient contacts outside of traditional face-to-face office visits.^5,67

In addition to efficacy studies of the health care home model, other research demonstrates the clinical improvements and savings of key elements of the model. For children with special health care needs, the benefits of care coordination include statistically significant reductions in hospitalizations and missed work days for parents.⁶⁸ For adults, providing diabetes treatment consistent with the chronic care model is associated with improved diabetes management, lower risk of heart disease, and long-term health care savings.⁶⁹ Care coordination for patients with chronic illness is associated with reduced ED use.⁷⁰ The Healthy San Francisco model of comprehensive, coordinated care, an example of a safety net health program, has reduced nonurgent ED use for participating adults. The average cost of care per patient per month is lower than the national average for adult patients covered by employer-provided commercial insurance.⁷¹

In Arkansas, integration of primary care with care coordination for children with complex health care needs to ensure medical, nutrition, and developmental services at a hospital clinic has produced substantial savings for the state's Medicaid program. Two thirds of these children were born prematurely, and 37% were diagnosed with bronchopulmonary dysplasia, 33% with cerebral palsy, and 40% with a genetic syndrome or congenital anomaly. Savings have been achieved primarily through fewer hospitalizations and shorter stays when hospitalized. Ambulatory care visits increased and ED visits decreased, resulting in further health system savings. Overall, the analysis projects that care coordination produces savings to the state Medicaid system of $14 148 per medically complex pediatric patient per year.⁷²

The efficacy of the health care home model has been powerfully demonstrated in outcome studies of children with asthma.⁷³ In North Carolina, hospitalization and ED use, which are indicators of inadequate asthma management in primary care and hallmarks of asthma disparities, were substantially reduced, with significant decreases in Medicaid expenditures.⁷⁴ Savings of more than $4000 per pediatric asthma patient per year were found in an outcome study of a program that implemented evidence-based asthma care in an enhanced medical home model in New York City.⁷⁵ In addition, evidence shows that treatment of children with asthma in the health care home model improves school participation and quality of life.⁷⁶

Electronic health records, another important element of the model, are associated with increased use of guidelines-based best-practice protocols,⁷⁷ facilitated care coordination, flow of information among multiple providers caring for a patient with complex health care needs,⁷⁸ increased receipt of preventive services,⁷⁹ and increased patient-centered care. These achievements are attributable to encouraging nontraditional contacts (telephone and e-mail)⁸⁰ and improving patient self-management and adherence to medication (text, e-mail, and Web reminders). Health information technology achieves an additional public health goal by strengthening the public health infrastructure through electronic exchange of information between primary care practices and public health agencies (e.g., immunization registries, follow-up for newborn screening, preventive care, and clinical practice guidelines).^81,82 Electronic health records facilitate creation of patient registries and contribute to population-based studies to determine chronic disease prevalence and disparities, which can inform public health policy.⁸³ Federal policy, including targeted stimulus funds, supports expansion of meaningful-use, prevention-oriented electronic health records to improve care coordination, ensure access and quality, and reduce costs. In some areas, this may also reduce the digital divide and improve provider compliance with best-practice guidelines.^84–86

CHALLENGES

Implementation and sustainability of the health care home model are limited by current reimbursement rates, which do not encompass the additional scope of practice associated with the model. Providing extended visits, incorporating care management and coordination, conducting more preventive screening, and attending to patients’ psychosocial needs leads to longer visits and less third-party revenue. Longer visits must be compensated by increasing the per-visit primary care reimbursement rate.⁸⁷ Broad implementation of the health care home model of primary care will require both practice redesign to support the expanded scope of services and improved financial support of primary care services.⁸⁸

Reimbursement for nontraditional patient contacts (e.g., e-mail) is essential to the successful implementation of the model,⁸⁹ as is reimbursement for multidisciplinary team meetings to facilitate coordinated care.⁹⁰ Inadequate payment for care coordination has been highlighted as a problem with Medicare reimbursement for patients with chronic conditions.⁹¹ This situation has worsened since Medicare stopped paying for consultation, affecting reimbursement for initial patient visits and for provider consultations in ambulatory and inpatient settings.⁹² Limitations are also imposed on reimbursement for management of psychiatric disorders in the primary care setting.⁴³ Costs associated with the use of electronic health records have also been identified as additional expenditures in implementing the health care home model,⁹³ although some of these costs have been offset by financial incentives.

A potential solution to some reimbursement obstacles to health care home implementation is recognition or accreditation of primary care practices as medical homes or health care homes eligible for higher reimbursement if paid by the state in which the practice is located. One source of recognition is the National Committee on Quality Assurance.⁹⁴ Initially this group only recognized physician-led practices; in October 2010 nurses became eligible to be the primary care provider in medical home–recognized practices.⁹⁵ The Accreditation Association for Ambulatory Health Care offers health care home accreditation,⁹⁶ and the Joint Commission Primary Care Home Initiative offers primary care home accreditation in addition to its Ambulatory Care Accreditation Program.⁹⁷

Potential higher reimbursement for the health care home model is available only for primary care practices. Significant reimbursement issues affect other health disciplines essential to achieving the goals of the health care home. For example, despite the emphasis on the health problems and costs associated with pediatric overweight and obesity, and the demonstrated efficacy of counseling by a registered dietitian,⁹⁸ nutrition services are not generally reimbursed in the absence of a diagnosis such as diabetes or hypertension.

Community Focus

The health care home model incorporates less involvement in the communities in which care is provided than does an alternative model, also developed in the 1960s: community-oriented primary care (COPC). The COPC model was recommended in 1982 by the Institute of Medicine to improve primary care because of its focus on social determinants of health within a geographically defined area. The COPC model engages the larger community and its resources (e.g., housing, parks, and other public spaces) in the delivery of health care services.⁸⁸ Although a review of the evidence of efficacy of the model found that program administrators had different interpretations of how to implement it, COPC contributed to improved care for medically underserved patients.⁹⁹ The COPC model was adopted as part of residency training for family practitioners in 1999.¹⁰⁰ It is not widespread in practice; reimbursement issues have made it difficult for COPC practices to sustain the necessary level of effort.^101,102

The community-centered health home extends the COPC model with a greater emphasis on socioeconomic determinants of health, environmental interventions, and health behaviors.⁸⁶ The notion of bringing this community-centered public health focus to the health care home is a positive enhancement of the model. Until reimbursement arrangements can be made that adequately support such activities, however, health care home providers are likely to consider achieving these goals through partnerships with their state or local health departments.

Providers and Clinics

An estimated 65 million Americans live in areas without an adequate supply of primary care providers to ensure timely access to health care when needed. The nation's supply of primary health care providers is inadequate to meet current needs.^103,104 The need for primary care providers will increase when more people are insured under the Patient Protection and Affordable Care Act of 2010.¹⁰⁵ Continuing nursing shortages are projected,¹⁰⁶ contributing to an ongoing primary care workforce shortfall in federally qualified health centers.¹⁰⁷ Access for low-income populations on Medicaid is worse still because low reimbursement rates often discourage provider participation in the Medicaid program.¹⁰⁸

In addition to linkages between health care homes and community resources, collaboration with other health care providers is essential to provide patients with comprehensive and coordinated care. The accountable care organization (ACO) model has been developed to better coordinate the efforts of diverse health care providers to prevent fragmentation and gaps in health care delivery. Provisions of the Affordable Care Act give states the opportunity to develop the ACO model to maximize value in health care delivery, emphasizing accountability and incentivizing positive clinical outcomes. The health care home is integral to the ACO model, with the enhancement of systems to support a continuum of care that includes specialists and hospitals.¹⁰⁹ The health care home provides care coordination services directly to the patient in an ACO infrastructure that facilitates the necessary level of interagency collaboration.¹¹⁰

Integral to the ACO model is alignment among participating health care entities regarding payment, cost, and quality of care. A 2011 survey of health facility administrators found that a majority agreed that the ACO model has the potential to contain costs while improving quality of care. The major barrier to participation in an ACO was difficulty establishing alignment among physicians and other key staff and in the interface between primary care providers and hospitals. Issues that remain to be resolved include leadership of these systems, reimbursement, and risk assignment.¹¹¹

ACTION

Despite the documented benefits of the health care home model for diverse populations and the ongoing effort to reform payment structures, the rate of implementation remains low more than 40 years after the concept was first introduced. The Center for Studying Health System Change found that fewer than one third of primary care physicians actively coordinated care for their patients with chronic conditions such as asthma, diabetes, congestive heart failure, and depression.¹¹² Among children with special health care needs, the population for whom the model was first proposed, federal survey data show that fewer than half (47%) benefit from coordinated, ongoing, comprehensive care in a medical home model.¹¹³ The need to redesign primary care consistent with the health care home model has become more urgent because additional patients are expected to require primary care when insurance coverage is expanded by health care reform legislation.¹¹⁴

In adopting its policy statement, APHA has committed to promoting the health care home model for all populations and calls upon all states to develop regulations that permit Medicaid and state child health insurance programs to reimburse certified health care practices, whether full or part time, fixed site or mobile, at a higher rate that is commensurate with the expanded scope of care provided. APHA also encourages commercial insurance providers to meet this challenge.

APHA endorses several steps to meet the need for an expanded primary care workforce. Nurse practitioners, advanced-practice nurses, physician assistants, and others as specified in state practice laws should be recognized as primary care providers in the health care home model, in addition to the full range of physicians who provide primary care services. APHA supports expanding funding for federal laws and programs intended to expand the primary care workforce (e.g., the Public Health Service Act¹¹⁵) and incentivize services in medically underserved populations (e.g., the National Health Service Corps¹¹⁶).

Reimbursement for disciplines that are essential to the health care home model should be improved, and APHA recommends increased payment to support services from mental health and substance abuse treatment professionals, oral health providers, nutritionists, hearing and vision care specialists, orthopedists, chiropractors, podiatrists, rehabilitation specialists, health educators, social workers, case managers, public health nurses, home visitors, interpreters and translators, patient navigators, and other specialists. It is also essential that enhanced primary care reimbursement be sufficient to support interdisciplinary team meetings required for effective care coordination.

The promising results of initial studies of the value of the health care home model in improving outcomes, reducing disparities, and lowering the cost of care for vulnerable populations should encourage additional efficacy studies. These studies should specifically target special populations that are most affected by health disparities, such as the homeless, children in foster care, and medically underresourced inner-city and rural populations. APHA also supports expanded funding to test the value of health information technology in community settings and to facilitate implementation of technological advances in community settings with currently inadequate technology resources.

Broader implementation of the health care home model is uniquely suited to coordinate point-of-contact health care services with public health goals and priorities. The health care reform legislation of 2010 and its timetable for implementation creates a supportive context for the expansion of the health care home model in practice and the development and assessment of outcome studies to further establish the efficacy of the model.

Acknowledgments

The health care home policy statement was the topic of a Community Health Planning and Policy Development Special Session at the 2010 Annual Meeting of the APHA. Important contributions to the statement were made by representatives of many APHA sections, including Medical Care (Mona Sarfaty, MD MPH), Food and Nutrition (Cynthia A. Peshek, MA RD), Mental Health (David Shern, PhD), and Public Health Nursing (Nancy L. Rothman, RN, EdD).

Human Participant Protection

Protocol approval was not needed because no human participants were involved.

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PERMALINK

The Health Care Home Model: Primary Health Care Meeting Public Health Goals

Roy Grant, MA

Danielle Greene, DrPH

Abstract

BACKGROUND

ROLE IN PUBLIC HEALTH

Reducing Health Disparities

Meeting Special Health Care Needs

Chronic disease management.

Mental health integration.

Women's health.

TESTING THE MODEL

CHALLENGES

Community Focus

Providers and Clinics

ACTION

Acknowledgments

Human Participant Protection

References

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

The Health Care Home Model: Primary Health Care Meeting Public Health Goals

Roy Grant, MA

Danielle Greene, DrPH

Abstract

BACKGROUND

ROLE IN PUBLIC HEALTH

Reducing Health Disparities

Meeting Special Health Care Needs

Chronic disease management.

Mental health integration.

Women's health.

TESTING THE MODEL

CHALLENGES

Community Focus

Providers and Clinics

ACTION

Acknowledgments

Human Participant Protection

References

ACTIONS

PERMALINK

RESOURCES

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