For years, the vanguard of the primary care community has been looking at ways to build a patient-centered medical home (PCMH), a primary care practice that coordinates all of a patient's care and works to treat its patient base as a population.
Now, some of the same thinkers are getting behind a bigger concept which turns the PCMH into the hub of a larger entity known as the Patient-Centered Medical Neighborhood (PCMN). In the PCMN, primary care practices are connected with other community-based healthcare providers to create a small but complete healthcare delivery system, including subspecialists and hospitals.
These PCMNs are often linked by a health information exchange, an integrated electronic network which allows PCPs to share data safely and securely with each other, into a link-up which facilitates coordination of care.
One major project testing out the viability of the PCMN is backed by American Academy of Family Physicians subsidiary TransforMED. TransforMED is partnering with VHA Inc., a national network of not-for-profit healthcare organizations, and healthcare IT company Phytel to foster the emergence of PCMNs in eight communities:
The project, which is supported by a three-year, $20.75 million grant from CMS, is part of a larger initiative in which TransforMED and the agency are looking at new models for the delivery of quality care through Medicare, Medicaid and the Children's Health Insurance Program.
Starting in February of this year, healthcare organizations in eight U.S.communities kicked off their training programs designed to launch their PCMN:
- Via Christi Health, Wichita, Kan.
- Owensboro Medical Health System, Owensboro, Ky.
- Western Connecticut Health Network, Danbury, Conn.
- Marquette General Health, Marquette, Mich.
- North Shore Physicians Group, Salem, Mass.
- Orlando Health, Orlando, Fla.
- Avera Health of Sioux Falls, S.D.
- Novant Health, Winston-Salem, N.C.
The goal, in each of these cases, is help primary care practices achieve medical home status, then to connect them with hospitals and specialists in their respective areas as part of a medical neighborhood.
While connecting up via an HIE is important, that's not all that they do. Practices and the subspecialists they work with grow to rely on common definitions of care transitions, allowing them to know who is responsible for what in caring for the patient.
At Westminster (Colo.) Medical Clinic, for example, PCPs know exactly what their role is their medical neighborhood, and that means far less fragmentation of care, said the clinic's R. Scott Hammond, MD. "The only way you can truly coordinate care is by defining your roles, responsibilities and accountabilities and getting all the clinicians on the same team with your patient," Dr. Hammond told AAFP News Now.
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