The Patient Centered Medical Homeless

The other night my wife and I had dinner with friends. Both are over 65, and, as you would expect, both have experienced some recent health problems. We try to avoid conversations about politics, but, inevitably, the state of the sick-care system weaseled its way into the conversation. The subject of conversation was that they both had recently been informed that their primary doctors were changing to a concierge model.

When I asked if they were going to pay the freight, even though they were insured by Medicare, they both responded without hesitation, “You bet. I'm afraid I won't be able to find a doctor to take care of me. I had a hard enough time finding this one.” The also commented that their experience with the patient centered medical home did not feel real homey.

According to the AAFP, the patient-centered medical home (PCMH) is a model of care that aims to transform the delivery of comprehensive primary care to children, adolescents, and adults.

“Through the medical home model, practices seek to improve the quality, effectiveness, and efficiency of the care they deliver while responding to each patient’s unique needs and preferences. No matter where you fall on the spectrum of PCMH transformation—managing current projects, enhancing basic concepts, or advancing to more complex initiatives—the adoption of PCMH concepts can benefit your practice, your patients, and your bottom line.”

Here is what is supposed to happen:

• Physician-led practice: Patients have access to a personal physician who leads the care team within a medical practice. Unfortunately, there are fewer and fewer doctors, even using non-MD providers, to take care of more and more patients, so finding one can be a problem. As in the case of my friend, some are switching to concierge models.

• Whole-person orientation: The care team provides comprehensive care, including acute care, chronic care, preventive services, and end-of-life care, at all stages of life. Throwing in population health, data management, nutritional counseling, physical fitness education, family and caregiver instructions, mental and behavioral health, socioeconomic determinants of health outcomes, and all the rest of the administrivia creates unrealistic expectations. Primary care needs to be unbundled. Bundling all these roles does not create a pretty package wrapped up in a bow. Instead, it just ties doctors up in knots.

• Integrated and coordinated care: Practices take steps to ensure that patients receive the care and services they need from the medical neighborhood, in a culturally and linguistically appropriate manner. With rising out-of-pocket costs, higher and higher drug prices, and wage stagnation, good luck finding a house in a medical neighborhood you can afford.

• Focus on quality and safety: Practices use the quality improvement process and evidence-based medicine to continually improve patient outcomes. Adhering to evidence based-guidelines is a double edged sword, and, as a result, only 50% of doctors adhere to them.

• Access: Practices commit to enhancing patients’ access to care. Here are the numbers. In many instances, the wrong patients are going to the wrong places for the wrong reasons. Some have no place to go. For others, care delayed is care denied. Just ask the Secretary of the VA how that's working.

Many patients, it seems, feel patient centered homeless. You won't find them sleeping in the streets on in shelters, but they are homeless nonetheless, and the rate seems to be increasing.