CareOregon offered a grant to the five community health centers to work on Primary Care Renewal, which would be guided by five principles: it would be a customer-driven system instead of a schedule-driven one; it would focus on the relationship between the clinic staff and the client; employ a team-based approach; embrace proactive care so that instead of, say, waiting for a fifty-five-year-old woman to call and schedule a mammogram, the clinic would call her; and it would integrate behavioral health. Behavioral health turns out to be important, since, as Labby puts it, the way a patient takes care of himself between doctor visits is what’s most important to health.
The foundations for the idea of medical home began in the late 1960s, when parents of kids with complex health problems complained that their children’s medical records were scattered among many physicians and locations. “The system was fragmented; no one was in charge,” Labby says. In response to the problem, the American Academy of Pediatrics coined the phrase “medical home” in 1967, arguing that what parents needed was a centralized place for medical records and a coordinating doctor.
With its definition much expanded and primary care in shambles, the medical home model today is being hailed as a way to solve the health system’s problems. It’s been touted by the four largest trade associations representing primary care doctors, including the American Academy of Pediatrics and the American College of Physicians, and even by President-elect Barack Obama. The medical home also figured into the 2007 Healthy Oregon Act, which directed the Oregon Health Fund Board to revamp the Oregon Health Plan and develop a state health program that, among other things, emphasizes preventive care and chronic disease management and “promotes a primary care medical home.”
But a considerable knowledge gap remains between the medical home as a theory and a practice. Few clinics have tried to implement the model, which means that no one really knows how or if it could work on a large scale. Locked into a fee-for-service insurance system, clinics have no incentive to hire medical assistants and nurses, who are integral to the team-based approach to care. “… [The] current policy buzz may be stimulating unrealistic expectations about the medical home’s immediate potential,” a group of doctors, including two from the respected Washington, DC–based think tank the Urban Institute, wrote in the September/October issue of Health Affairs, noting that the medical home model requires successful demonstrations showing how it might operate in a day-to-day clinical setting. “It would not be the first time that a good health policy idea was judged to be a failure because of premature promotion.”
That’s why Labby and other medical home enthusiasts argue that projects like CareOregon’s are so important. Without evidence that it can and will work, the medical home, which on paper reads like a perfect antidote to primary care’s ills, may remain theory alone.
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