Beyond the walls of the medical home

Picture your home: your front door, your favorite place to read, your bedroom, your patio. Now imagine your home in the midst of a slum, bounded on every side by ramshackle buildings, deafening noise, and mountains of debris.

Could this be the future of the patient-centered medical home? Are we becoming too myopic, in effect developing a highly functioning island in a sea of dysfunction? To avoid that fate, we need to look beyond our office walls at the larger environment in which we practice.

What will it take to create patient-centered medical communities? Here are some thoughts that come to mind:

Specialty care. Like it or not, many primary care patients will continue to get specialty care—when it’s appropriate and, at times, when it’s not. What standards for 2-way communication and care planning do we expect? How do we rationally choose specialty services based on outcomes and specialists based on competence and efficiency? What should we do if our patients prefer to “live” in other houses—with the cardiologist, the nurse practitioner, or maybe even the naturopath?

Patient handoffs. What standards do we expect for handoffs to other homes, including temporary ones such as hospitals, nursing homes, or hospices? Electronic communication will help, but we still must ensure that every member of the health care team has the just-in-time information that’s crucial to decision making.

How can we collaborate with clinicians in settings such as emergency departments and urgent care clinics? How can we align incentives?

Public health. What kind of coordination do we need with the mental health/behavioral health and social services communities, and other public health partners? Is it realistic to expect family physicians to be the arbiters for all such services? How can we reform the payment and carve-out structure to make mental health services available in our practices—and what services should we routinely refer patients to other practitioners for?

Finally, how do we judge the success of the medical home—on the basis of our services alone, or on the integration of our services with others in the community?

Without thought to the development of communities where all care is accessible, coordinated, patient-centered, and efficient, I fear, we’ll build fine medical homes in an old, blighted neighborhood where no one’s expectations are met.

Picture your home: your front door, your favorite place to read, your bedroom, your patio. Now imagine your home in the midst of a slum, bounded on every side by ramshackle buildings, deafening noise, and mountains of debris.

Could this be the future of the patient-centered medical home? Are we becoming too myopic, in effect developing a highly functioning island in a sea of dysfunction? To avoid that fate, we need to look beyond our office walls at the larger environment in which we practice.

What will it take to create patient-centered medical communities? Here are some thoughts that come to mind:

Specialty care. Like it or not, many primary care patients will continue to get specialty care—when it’s appropriate and, at times, when it’s not. What standards for 2-way communication and care planning do we expect? How do we rationally choose specialty services based on outcomes and specialists based on competence and efficiency? What should we do if our patients prefer to “live” in other houses—with the cardiologist, the nurse practitioner, or maybe even the naturopath?

Patient handoffs. What standards do we expect for handoffs to other homes, including temporary ones such as hospitals, nursing homes, or hospices? Electronic communication will help, but we still must ensure that every member of the health care team has the just-in-time information that’s crucial to decision making.

How can we collaborate with clinicians in settings such as emergency departments and urgent care clinics? How can we align incentives?

Public health. What kind of coordination do we need with the mental health/behavioral health and social services communities, and other public health partners? Is it realistic to expect family physicians to be the arbiters for all such services? How can we reform the payment and carve-out structure to make mental health services available in our practices—and what services should we routinely refer patients to other practitioners for?

Finally, how do we judge the success of the medical home—on the basis of our services alone, or on the integration of our services with others in the community?

Without thought to the development of communities where all care is accessible, coordinated, patient-centered, and efficient, I fear, we’ll build fine medical homes in an old, blighted neighborhood where no one’s expectations are met.

Picture your home: your front door, your favorite place to read, your bedroom, your patio. Now imagine your home in the midst of a slum, bounded on every side by ramshackle buildings, deafening noise, and mountains of debris.

Could this be the future of the patient-centered medical home? Are we becoming too myopic, in effect developing a highly functioning island in a sea of dysfunction? To avoid that fate, we need to look beyond our office walls at the larger environment in which we practice.

What will it take to create patient-centered medical communities? Here are some thoughts that come to mind:

Specialty care. Like it or not, many primary care patients will continue to get specialty care—when it’s appropriate and, at times, when it’s not. What standards for 2-way communication and care planning do we expect? How do we rationally choose specialty services based on outcomes and specialists based on competence and efficiency? What should we do if our patients prefer to “live” in other houses—with the cardiologist, the nurse practitioner, or maybe even the naturopath?

Patient handoffs. What standards do we expect for handoffs to other homes, including temporary ones such as hospitals, nursing homes, or hospices? Electronic communication will help, but we still must ensure that every member of the health care team has the just-in-time information that’s crucial to decision making.

How can we collaborate with clinicians in settings such as emergency departments and urgent care clinics? How can we align incentives?

Public health. What kind of coordination do we need with the mental health/behavioral health and social services communities, and other public health partners? Is it realistic to expect family physicians to be the arbiters for all such services? How can we reform the payment and carve-out structure to make mental health services available in our practices—and what services should we routinely refer patients to other practitioners for?

Finally, how do we judge the success of the medical home—on the basis of our services alone, or on the integration of our services with others in the community?

Without thought to the development of communities where all care is accessible, coordinated, patient-centered, and efficient, I fear, we’ll build fine medical homes in an old, blighted neighborhood where no one’s expectations are met.