The patient centered medical home model (PCMH) has emerged as one of the key elements of contemporary healthcare reform. While the PCMH was first articulated within the field of pediatrics nearly 50 years ago, it has subsequently been adapted to a number of different primary care settings (e.g., general internal medicine, family medicine), as well as specialty care settings (e.g., obstetrics and gynecology, oncology, and HIV care). The PCMH is receiving particular notoriety as a solution for the care coordination, cost escalation, and accessibility crises. Its advantages are variably framed in economic, safety, quality, professional satisfaction, and patient satisfaction terms: PCMH has the potential to reduce costs while improving safety, quality, job and patient satisfaction, as well as clinical outcomes. As I mentioned in the paper I gave at the 2012 SfAA meeting in Baltimore, the current scaling of PCMH implementation is unprecedented and is something that anthropologists should take note of: these projects provide a living laboratory of large-scale organizational change and signal a confluence of ideas about the weaknesses of the national healthcare system in its current form. The study of PCMH also reveals our societal and disciplinary beliefs about the normative roles for healthcare providers and patients (aka consumers) alike.
But what is PCMH exactly? And can we as anthropologists resist our inclination to reject such models out of hand because of their reliance on tropes such as “home” long enough to give PCMH considered critical engagement? For patients, a PCMH is a centralized location that serves as both a physical and digital hub for medical records and care coordination. Patients can access medical care, scheduling services, educational materials, their medical records, and lab results, often through secure health portals. The PCMH team is responsible for coordinating their patients’ care with medical specialists and other healthcare providers as the need arises and for organizing communications across specialty services using a centralized medical record, either on or offline. This notion of a homeplace is steeped in a thick discourse concerned with providing culturally competent, patient-centered care in an efficient, accessible, and technologically flexible manner. Patients should be made to both feel “at home” in their PCMH and to consider their PCMH a “home” for their medical information and care.
For healthcare workers, PCMH is a model for organizing the people who provide you with healthcare in such a way as to maximize each person’s individual skill set and create a sense of ownership among this healthcare team for their patients. In doing so, patients are managed as both individuals in a personalized way and as an epidemiologic panel. The healthcare team analyzes their performance providing care to their patient population, reviewing measures such as their panel’s blood pressure, influenza vaccination rates, tobacco use, or other clinical indicators, and designs processes such as improved reminders, group visits, or educational materials to improve healthcare–related outcomes. The healthcare team also reviews systems data such as the amount of time it takes patients to complete an appointment or to gain an appointment, and empirically tests strategies to reduce clinic wait times or improve access.
These activities, in sum, change the roles of the healthcare team in 2 dimensions: first, individual tasks are assigned according to the licensure rather than culture of practice within the team; secondly, all activities within the team are reoriented from a reactive, acute care model to a proactive, chronic care model. These changes promise to reduce the traditional hierarchy within clinical teams linked to licensure, especially that of the doctor-nurse dyad, and broaden responsibility for patient care from simply that of the lone physician to the job of the healthcare team. Patients visiting their medical homes are seen by their physicians, but also by their team nurse or paraprofessionals who can provide educational resources that don’t require an MD credential.
PCMH also changes the professional nature of individual roles within the healthcare team. The physicians’ job is no longer simply to take care of the patient in front of them: The physicians’ job is to analyze a broader range of patient data and to make decisions such as whether scheduled appointments could appropriately be managed through telephone, by the nursing staff, or through a secure e-mail message and to determine whether the clinical decisions the team makes are improving the health outcomes of their patients by condition. Nursing staff are more directly involved in chronic disease management, using techniques such as motivational interviewing to help their patients find ways to integrate health behavior into their lifestyle. The professional roles of administrative staff are increased, too, with new tasks that extend beyond scheduling and billing activities to pulling data, preparing reports, developing patient orientation materials, and running meetings. What is described as “working at the top of one’s license” in the PCMH literature is coupled with working as a team, and PCMH teams spend time working on both improving clinical care and developing team function in order to have more harmonious workplaces with less emphasis on status and more emphasis on working together.
If you’ve sought healthcare through a primary care clinic in the US in the past year you’ve likely already seen some of what a PCMH has to offer: Have you called to make an appointment with your doctor only to be transferred to a nurse for health counseling and home care? Are you now able to make appointments or view your lab results through online health portal? These changes are taking place in both private and public healthcare markets and compel thoughtful study and reflection. The PCMH literature, with its references to hierarchy, homes, satisfaction, “patient-centeredness”, and quality offers a rich landscape for anthropologists, whose disciplinary grounding is in revealing how these discursive connections transparently reflect who we are, our value system, and prevailing power structures within social systems and organizations. It’s enticing to “other” the sweeping language of PCMH, but I would caution that we engage this research with an eye towards being actionable as well. As an American citizen working in US field sites, it sometimes feels more permissible to loosen our standards for relativism and respect when we turn the gaze towards allopathic medical practitioners and the US healthcare machine. As heady as the PCMH discourse might seem, access to affordable, safe healthcare remains a serious concern for millions of people and it’s possible that PCMH may constitute a potential channel to ameliorate some of the challenges facing both patients and healthcare providers.
Sarah Ono, Heather Schacht Reisinger, and Samantha L. Solimeo
*****The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.*****
If you’ve sought healthcare through a primary care clinic in the US in the past year you’ve likely already seen some of what a PCMH has to offer: Have you called to make an appointment with your doctor only to be transferred to a nurse for health counseling and home care? Are you now able to make appointments or view your lab results through online health portal? These changes are taking place in both private and public healthcare markets and compel thoughtful study and reflection.