Medical Home Preparedness

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Are pediatric practices ready for medical home certification?

The American Academy of Pediatrics (AAP) in 1967 introduced the medical home concept, which initially referred to a central location for archiving a child’s medical record.¹ In 2002, the AAP expanded the medical home concept, recommending that it be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.²

Zickafoose et al³ designed a study to assess how well prepared pediatric primary care practices are to apply for medical home certification, as well as to identify practice characteristics associated with medical home infrastructure. Their cross-sectional analysis mapped survey items from the 2007 and 2008 National Ambulatory Medical Care Survey (NAMCS) to the 6 standards set forth in 2011 by the National Committee for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) program.⁴ The 6 PCMH standards cover enhancing access to and continuity of care; identifying and managing targeted patient populations; planning and managing care; supporting patient self-care and community resources; tracking and coordinating care; and measuring and improving performance.

The sample comprised 222 primary care pediatric practices and 398 family and general practices. Each practice received a score reported as a percentage of maximum possible medical home infrastructure points; these points were based on practice characteristics extrapolated from NAMCS data.

All told, 78% of visits were to the pediatric practices, most of which were solo or 2-partner physician-owned practices. Most pediatric patients were seen in large metropolitan areas. The pediatric practices saw a higher proportion of visits covered by Medicaid and the State Children’s Health Insurance Program.

Practice size was the key factor in practices that had the infrastructure required for medical home certification. On average, pediatric practices met 38% of possible medical home infrastructure points, while family and general practices met 36% of the possible points, showing that a significant proportion of practices would not qualify for the lowest certification level based on PCMH standards. Most practices met PCMH standards for enhanced access and continuity and for supporting self-care and community resources. But less than half of practices met the standards for planning and managed care, for tracking and coordinating care, and for measuring and improving performance.

Low scores in these standards largely were related to the fact that few practices had computerized systems that facilitate patient management tasks such as writing prescriptions, ordering tests, viewing laboratory results, and measuring and reporting quality of care. In bivariate analyses, the medical home infrastructure score was associated significantly with the size of both pediatric and family practices, with smaller practices having lower scores.

The authors noted the following limitations of the study:

•The study was based on the PCMH certification program, which is the most widely used program but which has been criticized for relying too heavily on process measures, particularly health information technology.

•The authors were able to assess only 56 of the 100 points in the PCMH standards and only 3 of the 6 must-pass elements. 

•Mapping of NAMCS items to PCMH elements was indirect for several items.

•The NAMCS data were from 2007 and 2008, and it is unclear whether policies and programs promoting the medical home in the last 5 years would have increased or closed gaps in practices’ medical home infrastructure.

The medical home concept has become a central part of efforts to improve delivery of primary health care and control costs. To participate in medical home programs and qualify for additional reimbursement, practices typically must go through a certification process. This study points to the idea that practices, particularly smaller ones, should invest in medical informatics as they prepare to create a patient-centered medical home.

REFERENCES:

1. Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics. 2004;113(suppl 5):1473-1478.

2. American Academy of Pediatrics Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110(1, pt 1):184-186.

3. Zickafoose JS, Clark SJ, Sakshaug JW, Chen LM, Hollingsworth JM. Readiness of primary care practices for medical home certification. Pediatrics. 2013;131(3):473-482.

4. National Committee for Quality Assurance (NCQA). Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2011. Washington, DC: National Committee for Quality Assurance; 2011.