nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Thursday, July 15, 2010

The Medical Home: Integrated Care, Or Care By Committee?

 
The medical home has been pushed by reformers as a way to bring together patients care, increase efficiency, and reduce duplication and error.  So far, the evidence is mixed.

People get the wrong idea of the "medical home" concept.  The term doesn't imply that there's a place, a "home," where health care occurs.  Care is still delivered in the doctor's office.  The difference is in how that occurs.  Instead of encountering the health care system as a series of fragmented events, the medical home attempts to integrated everything from disease management, prevention, physical therapy, social services, and all the rest into one seamless team-based approach to a patient's total needs.   It's a virtual "home."

Say you break your leg.  The physician, physical therapist, home nurse, psychologist, and social worker meet as a team to design comprehensive care for your problem.  At the same time that your healing leg is being managed by the doctor, the physical therapist has a program to keep your limbs and joints strong, the home nurse has a plan to visit and make sure you're on track with medicines and activity.  The social worker arranges for assistance if you can't take care of yourself in the acute phases.  Combined with electronic records--which all team members access, update and monitor--the entire team is up-to-date on your status, tracking your progress, and intervening if problems arise.

Team approaches to health care have been around for decades in one form or another.  The rudiments have existed for over a century as doctors and nurses have done regular ward rounds.  What makes the medical home new is its attempt to provide comprehensive care and to leverage computer health record technology.

What sounds great in theory has some issues, though.  As with most new programs where people sat down and tried to engineer an optimal process, the practical hurdles and unintended consequences surfaced almost immediately.

One peripheral issue is electronic medical record systems.  Policy makers are currently experiencing a backlash against poorly designed systems.  Commercial products have been put in place that led to patient treatment errors, and in one blockbuster case, a multi-billion dollar government system is under heavy fire after five years of struggling to make it work right (The DoD's AHLTA).

But the electronic record piece of the medical home concept is peripheral.  The real issue is the patient.  How well do they engage in the process, to their benefit and cost effectiveness, and how do they perceive it?

There have been warning signs that patients may not value evidence-based medicine in their care ( a study in Health Affairs, 3 June).  While most studies show improved quality of care and reduced cost, not all do.  And finally, some patients feel displaced and disoriented, uncertain that the new approach is bettering their care.

As with any endeavor that provides services to real human beings, the danger is in focusing on the process of caring over the well-being of the persons under your care.  People who complain about the corporate dehumanization in medicine, see the medical homeas  another step toward transforming them into an object, a collection of data points undergoing optimization in a scheme of care, rather than an individual with unique needs, strengths and weaknesses.

As Dr. Pauline Chen writes in the NYT (July 15)
"Yes, they were getting into their doctors’ offices more quickly and were being followed more closely than ever before, but many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them."
I was on active duty in the Air Force when we began using team approaches two decades ago.  It was difficult for patients to see how it made things better, and we were spending so much time in team meetings doing care plans that it ate into the time available to see patients.  It was difficult to sustain team momentum in the face of documentation required to keep the team up to speed.  Doctors would miss team planning due to emergencies, other team members would substitute in the absence of the regular team member, knowing little about the patients currently under treatment...so continuity suffered.  Feedback from patients was that it felt like being treated by a committee.  Engagement by the patients and commitment from the staff waned regularly and had to be reinvigorated.  When I retired from the military 3 years ago, these were still challenges.

Looking at the newest version of integrated care, the medical home, and thinking back on more simple efforts I was involved in, I think we'll continue to see these challenges.  But rather than seeing them as temporary impediments, I think they are inherent in a system of care that applies "scientific" methods to policy and management.  Any good manager can make the statistics look good on access or quality:  we all know how to pursue a desired data point.  But as long as the model is focused on how well WE are doing in taking care of people, the tendency by doctors, nurses, and other team members will be to look at the process--and a statistical measure of success--instead of a unique judgment about how individuals are getting along.

Whether it's Management by Objectives or Six Sigma, management philosophies come and go with great regularity.  You can bet we'll see the same in health care management (remember Managed Care in the 90's?  a flop).  There will be a lot of enthusiasm for medical homes for a few years, then it, too, will fade to make way for the latest great idea. 

That will be the fate of every program to address the "how" of health care over the actual well-being of individual persons:  it will feel like a visit to the DMV.

Doc D

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