Medical home is rolling out with great variability, no proven cost savings

The patient-centered medical home (PCMH) holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine the effects on clinical and most economic outcomes, based on a systematic review published Feb. 5 in the Annals of Internal Medicine.

As defined by physician and consumer groups, the core principles of the PCMH are the following: wide-ranging, team-based care; patient-centered orientation toward the whole person; care that is coordinated across all elements of the healthcare system and the patient's community; enhanced access to care that uses alternative methods of communication; and a systems-based approach to quality and safety. The authors noted that “it is being widely implemented by provider organizations and third-party payers.”

With this review, George L. Jackson, PhD, MHA, from Durham Veterans Affairs Medical Center and Duke University Schools of Medicine and Nursing in Durham, N.C., and colleagues sought to describe approaches for PCMH implementation and summarize evidence for effects on patient and staff experiences, process of care and clinical and economic outcomes.

The researchers conducted a review of PubMed through Dec. 6, 2011, the Cumulative Index to Nursing & Allied Health Literature and the Cochrane Database of Systematic Reviews through June 29, 2012, to gather English-language trials and longitudinal observational studies that met criteria for the PCMH, as defined by the Agency for Healthcare Research and Quality, and included populations with multiple conditions.

In 19 comparative studies, PCMH interventions had “a small positive effect” on patient experiences and “small to moderate positive effects” on the delivery of preventive care services (moderate strength of evidence), Jackson et al found.

“Our review identified important gaps in currently available evidence on the effects of PCMH. Most studies evaluated effects in older adults with multiple chronic illnesses; few studies were conducted in pediatric or general adult primary care populations,” they wrote. “Effects on quality indicators for chronic illness care and on clinical outcomes are uncertain.”

Staff experiences also were improved by a small to moderate degree (low strength of evidence).

Finally, evidence suggested a reduction in emergency department visits but not in hospital admissions in older adults (low strength of evidence).

Importantly, there was no evidence for overall cost savings.

Despite the impetus for PCMH implementation and agreement on broad concepts, such as enhancing team-based care and patient access, the exact approaches to PCMH implementation vary broadly, Jackson and his colleagues concluded. “This review indicated that PCMH is a conceptually sound approach to organizing patient care and appears to hold promise, especially for improving the experiences of patients and staff involved in the healthcare system. Evidence points to the possibility of improved care processes; however, ongoing and future studies are needed to determine whether these improvements translate into improved clinical outcomes or economic benefit.”