STEPHEN LEEDER. Home (not so) sweet home

Apr 17, 2018

Medical homes, where you as a patient are known personally by name and history and where a team of health professionals, generally led by a general practitioner, arrange and provide your care, have not taken off as expected. Why? 

Origins of ‘medical home’

The medical home – no relative of the nursing home – as originally proposed, was to be a place in the community where people would have their medical needs met in a continuous and timely fashion. The medical home is where you as a patient are known personally by name and history, and where a team of health professionals, generally led by a general practitioner, arrange and provide your care.

In a medical home there would be a group of GPs, supplemented with nurses and other health professionals, so the name ‘medical’ is incomplete. A GP consultation, physiotherapy, possibly radiology and pathology would be within easy reach. It would have top quality communication with hospitals and specialists who cared for you.

Wikipedia provides a history of the development of the medical home, a concept first articulated by the American Academy of Pediatrics in 1967 to offer coordinated care for children and their families, especially those with special needs. The idea has gathered support and since 2002 other US academies – general practitioners, surgeons and osteopaths – have joined in.

Desirable qualities have been defined in the US that a medical home must demonstrate to be accredited. Medical homes are places where, according to the accreditation principles, you would expect that each patient has their own doctor who will lead a team defined according to your needs as a patient, that high standards of quality and safety will be honoured, and performance of the whole practice is formally assessed against these standards, and where payment ‘appropriately recognises the added value provided to patients who have a patient-centred medical home’.

In the opposite circumstance, where components of care are not joined up between hospitals and the community, minor complications and flare-ups of the illnesses may not be treated in time, often then necessitating hospital admission.

The patient in the ideal medical home would be the centre of attention, and hence the name Patient Centred Health Care Home or PCHC was adopted in the discussion about their role in Australia.

Coordinating services among many carers, both in hospital and at home, is a serious management task, and not many medical practitioners are trained to meet it. Hospitals are in a relatively strong position because of their infrastructure and range of specialties. For a general practitioner this is challenging unless he or she has a back-up organisation such as a group practice or a meso-level primary health organisation such as our Primary Health Networks.

The change from conventional medical care in the community to PCHC would require additional funding, but the argument ran that this would be offset by savings from reduced hospital costs for the care of patients who required admission for problems that might have been prevented with better care at home. PCHCs would require doctors in them to operate differently to the way they worked when fee-for service was the principal method of payment. That is where the wheels fell off.

Enter ‘health care homes’

Last year Health Care Homes (note the change of name from PCHC) were endorsed by the Commonwealth Department of Health. This model differs from the PCHC, so now we have a third name for these entities.

The first 22 Health Care Homes (HCHs) had opened their doors to patients with chronic illness by December, 2017. The federal government agreed to pay the homes $600 a year for the complete care of patients with mild chronic problems and $1800 a year for those with serious illness. While these financial arrangements freed practices from the constraints of fee-for -service, the level of funding is proving inadequate, and the trial is not working as planned.

Once touted as the centre of health system reform, the medical home is in danger of being shifted off stage. Given the strong support for Patient Centred Medical Home principles by all relevant peak bodies, and the advice provided by these bodies on the limitations of the HCH as proposed, this would be a sad and entirely avoidable outcome.

This is not the first time Australia has tried to coordinate care based on general practice. Two previous large trials ended in failure. The entrenched system of paying for health care through fee for service is a major barrier. Even when this is bypassed to the extent that was tried in the current trial of the health care home, problems occur. Doctors feel they are out of pocket.

Where to from here?

What lessons can we learn? First, if the PCHC (or whatever we call it) is to prosper, serious change management is required. It cannot be planned in isolation from those providing the care. It is very difficult to try to manage change at the same time as saving money. The funding for PCHCs should be generous to get them started.

Second, comprehensive practice transformation is difficult and time consuming, and general practice is overstretched, under-remunerated, and lacking the necessary change management skills. Regional primary health organisations such as the Primary Health Networks (PHNs) have already demonstrated just how much work and investment is required on the part of both practice and PHN to shift gears.

Third, the planning of PCHCs should involve those providing the anticipated care. It cannot succeed unless this involvement is taken seriously. We are getting better at ensuring that the voices of patients and carers are heard when planning future health care but we are not so good at hearing what the implementers think of new ideas.

Amartya Sen, an Indian Nobel economist and philospherwith an intense interest in the interplay between economics and society, argues that the biggest errors in creating new policy occur because we do not think through the possible side effects of a new policy proposal.

This requires time and energy. Thought experiments can be helpful in sorting out what may go wrong before it happens but it is not clear as to the extent that this was done in detail by the Commonwealth prior to launch last year.

Fourth, Australia needs to accelerate its progress in finding forms of health care financing that are better fitted for purpose than is fee-for-service. Fee-for-service remains a good way of paying for acute episodes of care but as is increasingly recognised it is a poor fit for others, such as chronic long term care. PCHCs provide a good place to start the heavy lifting to improve our system of paying for health care, matching method to need.

This article contains material previously published in Australian Doctor.

Stephen Leeder is an Emeritus Professor  of public health and community medicine  at the University of Sydney. He is currently director,Research and Education Network,Western Sydney Local Health District and Editor in Chief of the International Journal of Epidemiology.

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