Coordination is the cornerstone of patient-centered care. And while the patient-centered medical home (PCMH) is designed to provide comprehensive, coordinated care, patients often require services that extend beyond the primary care realm. Outside the PCMH, though, that same level of coordination is often lacking. Specialists have long worked in care models that differ from those of their primary care counterparts. Additionally, patients may have access to any number of community resources, but not the wherewithal to take advantage of them.
Bringing specialists and nonclinical providers into the “medical neighborhood” is one approach to mitigating fragmented care, reducing frustration, and ultimately improving outcomes. Over the next month, we’ll talk with Emma Mandell about the concept of the medical neighborhood and why providers are embracing this transformative model of care delivery – and why patients are expecting them to.
Simply speaking, what is a medical neighborhood, and how does it differ from a patient-centered medical home?
The medical neighborhood is a clinical community that includes medical, behavioral health, and social/community services that are necessary to ensure comprehensive and coordinated patient care delivery. Some organizations like to call it the “medical home on steroids.” Essentially it’s an expansion of the PCMH, with the same foundation and the same key competencies. However, the PCMH has been a model that focuses mainly on primary care and doesn’t always expand beyond those walls to integrate specialty care, hospitals, community services, and other clinical and nonclinical support services. So the medical neighborhood takes that model to the next step, to ensure care coordination across all sites of care and across all providers involved in a patient’s care.
What types of entities or providers might you see in a medical neighborhood?
It can include primary care as well as specialty care, hospitals, behavior health services, home health, skilled nursing facilities, and other nonclinical providers such as community resources – things like transportation services, Meals on Wheels programs, public health agencies, and churches, all working to coordinate the needs of the patient in a more integrated and less fragmented manner.
The inclusion of specialty care is one of the most notable differences between the medical home and the medical neighborhood models. What makes this model appealing to specialists?
Specialists view the medical neighborhood as an opportunity to improve the way they deliver care by breaking down silos. Primary and specialty care providers want to be working together within a consistent model, coordinating care with hospitals and other sites of care. Doing so allows them to focus on providing clinical care to patients instead of worrying about other tasks.
And one of the tasks that occupies so much of their energy is referral management. Closing the loop on referrals continues to be an issue for both primary and specialty care providers. Patients are often referred between providers, but when it’s up to the patients to coordinate their own care, they sometimes get lost in the system without completing important tests and other services. So from a provider perspective, there’s certainly a lot of frustration over the inconsistencies stemming from primary care working in a different model than specialty care.
Additionally, specialists are starting to receive some of the same pressures from state and federal agencies that primary care has been experiencing for the last 10 years or so in terms of providing value-based care. For example, in some states, specialists are beginning to report certain quality and performance metrics, and they’re providing additional non-face-to-face services in terms of coordinating care. Unfortunately, some of these new value-based care requirements are not yet supported by value-based payment models. So specialists are shifting away from volume-based care delivery, but more slowly than primary care.
You mentioned how that lack of coordination frustrates providers. It must be worse for patients. How are they influencing this discussion?
As patients continue to become more savvy in their healthcare, they’re beginning to expect a high-quality, high-value model of care. So when patients move from a primary care setting, where their care is coordinated, to a specialty care setting where it may not be, frustration and confusion set in. When patients get frustrated, we begin to see an increase in gaps of care – patients don’t follow through with their care or recommended services, or they select a new provider.
It’s the same phenomenon you see across almost every industry providing services to consumers: services are catered to the individual consumer’s need and available when the consumer needs them; otherwise the consumer finds a new service provider. In healthcare, this means primary care providers and specialists must provide patient-centered care.
In addition, payors and providers are now marketing the idea of a medical home or neighborhood where care is patient-centered, comprehensive, and coordinated across the continuum. Some payors are even incentivizing patients to seek care at medical homes – for example, they’ll waive co-pays for certain services. So now patients are actually going to offices and asking whether they’re part of a medical home; and if not, they might take their care elsewhere because it’s more cost-efficient and effective. It’s a trend that’s likely to continue as the medical home and neighborhood become the standard of care that patients expect.
Emma Mandell is a Manager with ECG and has written extensively about care model transformation – including the medical home and medical neighborhood models. Her recent article, “It Takes a Village: Integrating the Medical Neighborhood,” appears in AMGA’s Group Practice Journal, and you can read it here.