Exploring the Role of Specialists in the Medical Home Model

Although the majority of discussions around medical homes have revolved around primary care physicians, there is a growing belief that specialists, including cardiologists, can play an equally significant role.

In a presentation entitled, “Designing the Medical Home for Heart Failure Patients,” delivered Wednesday at the HFSA 14th Annual Scientific Sessions, Mary N. Walsh, MD, St. Vincent Hospital, Indianapolis, IN, discussed the evolving model of the patient-centered medical home (PCMH) and how it involves healthcare professionals who treat heart failure (HF) patients.

The PCMH is built on several key principles, according to Walsh, including the following:

• The “personal physician,” who acts as the key contact for patients;
• A physician-led team that involves nurses and pharmacists, as well as other care providers;
• An emphasis on the “whole person,” which entails ensuring all care is met, including referrals to other physicians;
• Care coordination (a concept that is driven by healthcare information technology such as EMRs);
• Enhanced access, including expanded office hours and new methods of communication such as e-mail;
• Payment models where reimbursement is based on episodes of care.

The drivers of PCMH, she added, center around the growing trend toward consumer-driven health, increasing levels of patient engagement in their own care, and the need to improve outcomes based on performance measures. The way most models are designed, physicians are reimbursed per patient on a monthly basis, and in some cases, patients are billed separately for e-mail consultations, which Walsh says encourages “ongoing communication and helps build relationships.” In total, the costs for a medical home can run from about $23,000 to $100,000 (for practices that have not implemented an EMR system).

What isn’t as clear, she noted, is how the payment model for medical homes affects referrals to specialists, and whether cardiologists and other specialists can qualify as a PCHM. A case is being made, according to Walsh, that in many cases, cardiologists serve as a patient’s primary physician, and are the first person the patient contacts when he or she needs assistance. In this way, “we are already serving as the medical home for many of our patients,” she said.

Walsh urged clinicians to become familiar with the different PCMH models that exist—including the “neighbor” model in which a subspecialty practice works with a primary care physician to “enhance coordination of care and create transitions for patients moving through different components of care.” She also encouraged attendees to pay close attention to literature on medical homes, and consider joining a pilot program.

In another presentation, Misook L. Chung, University of Kentucky, Lexington, KY, discussed findings from a study that sought to determine whether depressive symptoms can predict quality of life (QoL) outcomes in both patients and their caregivers.

Chung and colleagues analyzed questionnaires given both to patients and caregivers, and utilized actor-partner interdependence model (APIM) regression to determine that depressive symptoms in patients acted as predictor of QoL both in patients and in their caregivers. They found that a very similar percentage of patients and caregivers reported depressive symptoms (22.5% and 20%, respectively), and that caregivers whose patients reporter higher rates of depressive symptoms demonstrated poorer QoL.

Further investigation is needed to determine effect of interventions with individuals on their partners’ outcomes, said Chung, who believes that more research can also “enhance our understanding of dynamic interactions in patient-caregiver dyads,” and help determine the most effective approach to improving outcomes for both patients and caregivers.