Improved Care of Complex Patients: Strengthening the Medical Home within a Health Care Neighborhood

This project was completed in September 2010. Click here to read the final report. Efforts are underway to secure funding to continue the Medical Home project, with a continuation of the partnership with the Family Care Network.

In July 2009, the Whatcom Community Foundation awarded a $100,000 grant to the Critical Junctures Institute, in partnership with The Family Care Network [FCN], Whatcom County’s principal primary care group practice, and the University of Washington Department of Family Medicine to study how the FCN “medical home model” can be enhanced to better serve “complex patients.”

This project can be considered action research because FCN’s physicians, clinical and administrative support staff, and patients, and CJI and University of Washington researchers are collaborating in reflecting and learning about how a primary care practice network can more effectively serve patients who use excessive resources, and who seemingly have benefitted little from FCN practice innovations such as pre-planned chronic care visits or quality improvement programs for immunizations, preventive screening, diabetes or heart failure.

What is a “medical home”?

Fostering the medical home concept has emerged as a cornerstone to health care reform (pdf) and sustaining the nation’s primary care delivery system.

The following are examples of changes in organizational structures and care processes in primary care that are likely to be implemented and sustained in transforming a primary care practice into a “medical home:”

1. Patient/family engagement. Enhanced evidence-based self-management practices.
2. Communication.  Improved communication within teams and between teams and patients and their families to enhance the efficiency and effectiveness of care. 
3. Integration and coordination of care.  Stronger and broader collaboration between a primary care practice and local health and human services agencies to help improve quality and cost effectiveness of care.
4. Improved work-life satisfaction for primary care team members. 

Coordination within primary care teams and with community services is critical in providing cost effective, high quality care, particularly for the complex patient.  However, there are few examples of successful coordination of care between primary care providers and community services in the U.S.

What elements of the medical home concept does your primary care practice have? Consider this American Academy of Family Physicians checklist (pdf).

Who is the “complex patient”?

Many, but not all, frail elderly persons; the chronically ill with multiple conditions, including mental illness; those who abuse substances; and patients who visit their physicians with persisting functional complaints are bewildered by the health care system, and who have benefited little from efforts to transform and improve primary care.

These complex medical patients are the most vulnerable to the deficiencies of a fragmented health care system and most in need of care coordination. Lack of care coordination may contribute to these patients using care that strains primary care practices, while failing to contribute to improving health outcomes.