Fee for Service health care models have created organizations that respond to needs in predictable ways–"If it is reimbursed, then do it–if not, avoid it." However, the Patient Centered Medical Home (PCMH) requires a different organizational culture. Some health care organizations are already aligned, others will require a sea change in thinking. But who is best suited to implement successful PCMH?

Joint Principles of the Patient Centered Medical Home

First, let's review the 2007 Patient Centered Medical Home Joint Principles outlined by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association (AOA):

There is no doubt that implementing the Joint Principles will require clinical expertise. However, much of the success will depend on managerial skills and organizational knowledge supported by a comprehensive technical infrastructure. Let's focus on the organization and managerial expertise because these must precede, or at least lock step, with both the clinical and technical components.

Below we examine a few organizational strengths needed to achieve the Joint Principles: strategic goal setting, process design, analytics and quality control, patient education and management, organizational learning, human resources, and of all things, contracting.

1. Strategic Goals

An organization whose strategic goals are aligned to increase shareholder value may struggle with the PCMH model. The model focuses on:

• Population Health
• Efficacy
• Patient Involvement and Compliance

These areas have done poorly in short-term Return on Investment (ROI) models. Long-term models effectively do not exist. The horizon of an ROI model is slippery. Setting it will require focus on standards of care that may take a very long time to validate. Patience will be needed.

2. Process Design

"Care is coordinated and/or integrated" implies the creation of a care life cycle. The content of care processes requires clinical expertise but the process design methodology is a systems thinking discipline. The need to adopt systems thinking to engineer clinical processes is clearly delineated in IOMs. (Building a Better Delivery System: A New Engineering/Health Care Partnership. 2005). For all eight points to fire correctly, they need to be part of an integrated business and clinical process design aligned with quality measures and outcomes.

3. Analytics and Quality Control

Few clinical organizations have learned how to effectively apply statistical process control to healthcare. As the volume of patients increases with healthcare reform, so does the volume of data. Reimbursement will depend on results. Statistical methods must be implemented that identify areas of improvement and prevent problems from occurring. Health care leaders are concerned about the supply of primary care physicians–we should also be concerned about the supply of statisticians or anyone who can create and explain a process control chart.

In addition, analytics and quality control must span organizations. This presents challenges–systems must not only integrate but also align on process and data definitions. This requires discipline and a set of analytics that manages data quality and process reliability.

4. Patient Education and Management

Are all clinicians good teachers? Can clinicians change patient behavior? Numerous private and CMS demonstration projects suggest not. Some of the more effective practitioners of patient change methodologies such as "motivational interviewing" experts claim that clinical practitioners are not wired to facilitate change. They suggest that we need a new profession. We can borrow from manufacturing here–every manufacturing quality program requires facilitators who are trained to move employee thinking from point A to point B. The facilitators are selected based on their interpersonal skills, which can be greatly enhanced by training.

5. Organizational Learning

The team approach required to execute care coordination may be a challenge. Manufacturing organizations have learned the need to "teach" people how to work in a team, regardless of education and position. The skills are not taught in our educational systems and a "physician directed medical practice" may not be consistent with the current working culture clinicians know. So, the ground rules and behavior must be spelled out and demonstrated. Everyone will require some training.

6. Human Resources

Good health care may be driven more by the relationships we have than by the medicine we take. Such is the message delivered in Malcolm Gladwell's Outliers, where he describles a group of Italian immigrants who began settling in Bangor, Pennslyvania in the 1880's. A 1960's study found that in spite of their diet and lack of exercise, they exhibited almost no heart disease. Their health was attributed to the relationship the individuals had with their tight-knit supportive community.

Further, SironaHealth's experience and research clearly identifies three drivers of patient satisfaction: Does the clinician care? Does the clinician respect the patient? And is the clinician knowledgeable? These skills can be emphasized and nurtured. They also can be taught.

Success of the Patient Centered Medical Home may depend in part by the organization's ability to maintain long-term employees who can have lasting relationships with their patients and who can meet the three requirements of caring, respect, and knowledge.

7. Contracting

Contracting is a very "nuts and bolts" skill that can consume enormous amounts of time. Care coordination implies that many organizations need to participate in a well-choreographed dance to ensure patient care and safety. This will require contractual underpinnings that are first defined in the "Care Life Cycle" mentioned earlier. Supplier and partner goals must be aligned with those of the Patient Centered Medical Home. These need to be spelled out in contractual relationships to ensure the goals are financially understood.

In Summary

Over the years, SironaHealth has worked with almost every kind of health care organization in existence. We also talk to patients 24x7x365. To a large degree, we have our hand on the pulse. This has given us a unique perspective. We believe that Joint Principles defining a Patient Centered Medical Home require an expertise in at least:

• Population Health
• Statistics
• Team Skills
• Change Skills
• Patient intimacy developed through long term relationships
• Care life cycle management
• Strategic contracting

So, to answer the question first posed: What organizations are best equipped to implement the Joint Principles of the Patient Centered Medical Home? You now have a few of the right questions to ask.