Primary care faces many challenges. Healthcare reform has and will continue to have a direct impact on primary care practices across the nation, with current trends in health care transforming nursing, advanced practice nursing, and the delivery of health care as we know it in a variety of ways. The implementation of patient-centered medical homes (PCMH) is one example of how economic constraints placed upon the current healthcare system have transformed nursing practice. Nurses and advanced practice nurses (APNs) will play an integral role in the implementation of new U.S. healthcare models such as the PCMH.
The concept of the PCMH
In their 2009 article, Robert J. Reid, MD, PhD, and colleagues described PCMH as a model of primary care in which a practice is redesigned to emphasize the core attributes of primary care: access, patient/provider relationships, and comprehensiveness and coordination of care. This redesign is intended to promote maximal use of advanced information technology, align reimbursement models, and improve patient outcomes.
The concept of the PCMH was developed in 2007 by primary care professional organizations, and has been endorsed by the major national health insurance plans and the American Medical Association. Under the direction of the National Committee for Quality Assurance (NCQA), the PCMH was developed as an extension of the Chronic Care Model to address the increasing incidence of chronic conditions in the United States by using a team-based approach to care. Managing patients as a team is a key element of an effective PCMH.
Reid’s research suggests that PCMH patients give higher ratings to their experiences with their care than patients who are not in a PCMH setting. PCMH patients also reported gains in quality of care, made greater use of phone and email communications with healthcare providers, and reported decreased use of emergency services. Although there is limited evidence about healthcare outcomes secondary to the implementation of a PCMH, Reid, et al. demonstrated that there were no significant differences between groups in overall reduction of healthcare costs. Therefore, further inquiry is needed into the experiences and quality of care among patients in a PCMH, as well as a research into related factors including cost.
Benefits of the PCMH
The PCMH has several benefits, including cost savings, improved quality of care, and culture change.
The PCMH is philosophically committed to reducing healthcare costs through its attention to the use of primary care preventive services, which reduces healthcare costs. Although we cannot yet show specific data demonstrating how the PCMH achieves cost savings, we know that paying careful attention to and participation in primary health care services prevents disease, and therefore promotes a reduction in services, which in turn reduces overall healthcare costs.
Maciosek and colleagues reported that greater use of proven clinical preventive services in the United States could result in a total savings of $3.7 billion, or 0.2% of personal healthcare spending. These startling statistics alone demonstrate the need for nurses and other providers to invest greater focus on preventive strategies with each and every patient encounter, and for policymakers to pursue options that move the nation toward greater use of proven preventive services. Financial incentives may also be offered by third-party payer systems for practices to use the PCMH concept so that savings can be shared.
Improved quality of care
The quality of care for patients enrolled in a PCMH may be improved. Research supports the effectiveness of nurses and APNs in the provision of quality healthcare in a variety of settings—primary care being just one example. As demonstrated by Fairman and colleagues, primary care services, such as wellness and prevention services, the diagnosis and management of many common uncomplicated acute illnesses, and the management of chronic diseases such as diabetes can be provided by NPs at least as safely and effectively as by our physician colleagues. It is, therefore, imperative that NPs commit to the opportunities for improved quality of care presented by active participation and engagement in all that the PCMH has to offer.
Specifically, in a PCMH the quality of care is enhanced through better coordination and a team approach to effective collaboration with patients who are truly engaged in the process. The PCMH mandates that each and every patient encounter encourages the use of primary care services. The patient care coordinator (PCC) plays a key role in promoting enhanced coordination of care. For example, the PCC team contacts each participating patient on a periodic basis to follow-up on lab results such as cholesterol screening and diagnostics such as mammogram and colonoscopy referral and compliance.
Quality of care can be improved through effective interprofessional team collaboration. The use of EHR systems promotes effective collaboration. All members of the team are given the ability to communicate and collaborate electronically using key elements of EHR. Examples include, but are not limited to, problem lists, medication lists, and documentation of personal/family/surgical/social histories.
The cultural change the PCMH model promotes is another worthwhile benefit to be aware of. In the PCMH, patients are no longer viewed as passive recipients of care. The PCMH requires patients to become active, prepared, knowledgeable participants in their care. The provision of quality care is fostered through the development of patient/provider relationships and positive patient engagement. It is well documented that better patient outcomes are achieved and overall costs reduced when healthcare organizations take steps to promote healthcare consumers taking a direct role in their own health preservation. The Institute of Medicine called for a greater focus on patient engagement in healthcare decisions to achieve better care outcomes. Therefore, an overarching goal of the development and implementation of a PCMH is to engage patients as stewards of their own healthcare needs.
Shared decision-making tools can be used effectively to allow meaningful conversations to take place between patient and provider. These strategies for enhancing the quality of primary care services and improving healthcare outcomes are priorities for a PCMH.
The role of nurses in the PCMH
As nurses, we are often the first providers patients contact in acute, chronic, and preventive care across the lifespan. It’s imperative that, as providers of primary care, we stay current on trends and developments in our healthcare-delivery environment. Nurses must become knowledgeable about what developing and implementing a successful PCMH entails, and we must also become proficient in what our expected role will be and how this role may, in fact, evolve over time—particularly as the implementation of the Affordable Care Act unfolds. However, there is a gap in the literature on the role of nursing and advanced practice nursing and the development and implementation of the PCMH. Specifically, there are no current studies describing healthcare outcomes as they relate to the role of nurses and APNs in a PCMH.
Starting a PCMH
There are no known drawbacks of developing a PCMH. Initial start-up costs include the salaries of a PCC team. Although there is also significant cost associated with implementing the electronic health record (EHR), it is essential. (See Incorporating technology in the PCMH.) Financial incentives for the implementation of EHR from the government and from third-party payers will help justify any costs of PCMH implementation. Legal risks are also minimized through better-coordinated primary care services and improvements in patient engagement.
Incorporating technology in the PCMH
Technology plays an integral role in the development and implementation of an efficient PCMH. The most prominent element of technology in the PCMH is the electronic health record (EHR) system. The EHR can be incorporated into the provision and management of high-quality primary care services, for example, by helping to ease access to the medical record, improving proficiency in receiving and reviewing diagnostic reports, enhancing communication between providers, ensuring prompt referral to specialty providers when necessary, and a wealth of other aspects of effectively coordinated healthcare services.
EHRs play a key role in collecting, organizing, and interpreting data so that important healthcare outcomes can be determined and reported. These are all key factors in an effective PCMH. The use of EHR systems is mandated by the government to help ensure proper reimbursements; practicing nurses must be current on standards of today’s practice environment and be immersed in strategies for proficiency in proper use of technological trends such as EHR.
EHRs also permit the provider to visualize the patient record instantly so that key data such as problem lists, immunization history, and medications are at the clinicians’ fingertips. Access to patient data from home or other practice sites is an additional feature that EHR systems offer providerd. It has been suggested that EHRs may need to be further developed to better support the PCMH. It may be necessary to improve areas such as telehealth, quality measures, and patient access to records as implementation of PCMH models expand. More research in this area is needed so that nurses may remain current on this new facet of primary care practice.
A PCMH case study: strategies for successful implementation
The following case study illustrates how nurses play a key role in a PCMH.
A multisite, multiprovider primary care practice in the northeastern United States successfully implemented a PCMH as a third-party-payer-supported program. Some key objectives of the transition to a PCMH included:
- improved key metrics such as compliance with recommended preventive screening
- controlled blood sugar, as evidenced by reported glycated hemoglobin levels in patients with diabetes
- blood pressure within guidelines for patients with hypertension
- a decrease in emergency department (ED) visits and 30-day hospital readmission rates
- a decline in referrals to specialty providers, and
- increased use of generic prescriptions when appropriate.
Another goal of the transition to a PCMH was that it be accomplished through a series of well-developed, strategized processes that took place over a determined period of time. An NP who has had experience in the successful development and implementation of several PCMHs was hired as a consultant to assist in the transition process.
The initial, and likely most important, step of the transitional process included the thoughtful education of the entire multidisciplinary team of personnel who were intimately involved with the development and implementation of the PCMH: receptionists, medical assistants, radiology technicians, administrative support, billers and coders, and providers (nurses, NPs, physician assistants, and physicians). Training took place independently as well as in groups to ensure maximum commitment by all involved. It is important to note how allowing for adequate training and transition time is highly encouraged to ensure that adaptation to a PCMH is a smooth and seamless process.
Another key part of the success of this PCMH has been the creation of the role of patient care coordinator (PCC). PCCs are trained nurses who are part of a team of nurses and administrators involved in supporting all members of the team in the process of adapting an existing successful primary care practice into a thriving PCMH. At least one PCC for each practice site is recommended. The PCC plays an important part in monitoring the medical neighborhood or the network of providers involved in caring for patients enrolled in the PCMH. For instance, the PCC oversees all patient communication and coordination of services, tracking of key preventive services, and determination of patient risk. The PCC team is also responsible for the measurement and reporting of performance.
Electronic record keeping is essential in the tracking of outcomes data. Key healthcare outcomes such as blood pressure, body mass index, blood glucose monitoring, and patient-driven outcomes such as patient perception of quality of care must be measured and evaluated periodically. An analysis of this outcome data will be reported in a future paper.
On the forefront
Today’s nurses and nurses in the years to come must be on the forefront of the effective and efficient incorporation of technology into the provision of quality care. The primary-care setting is just one example of a healthcare environment where technology, such as EHR, is essential in the development and implementation of economically sound, efficient, effective practices such as the PCMH.
Nurses, NPs, our physician colleagues, and all members of the multidisciplinary team must continue to partner in creative, innovative, and forward-thinking ways to be cost conscious, improve quality, and achieve optimal wellness for the patients we serve. All members of the healthcare team must adapt their current ways of thinking to promote the smooth transition from a traditional primary care practice to a PCMH.
Nadine M. Aktan, PhD, FNP-BC, is chairperson and professor of nursing at William Paterson University in Wayne, New Jersey.
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