Patient-Centered Medical Home Information Model - 2011

Summary: Currently, there is no standard definition or description of a patient-centered medical home (PCMH). Although descriptions may consist of sets of principles associated with the PCMH concept, the way PCMH core principles relate to the actual experiences of patients and providers within a PCMH is not clearly understood.

Dr. Steven Waldren and a study team from Westat developed a framework that links core principles and attributes of a PCMH to clinical activities and experiences (e.g., information flows) of patients within a PCMH. This framework can organize the elements of a PCMH, understand their relationships, and examine the information flows within and beyond the PCMH. By describing a set of clinical activities and experiences that are needed to support the PCMH, the framework can also guide the development of PCMH information systems.

Patients, clinicians, and others with an interest in PCMH can use this framework to better understand the effect of the principles found in PCMH literature on specific attributes and real-life experiences of patients within a PCMH. The framework also provides a prism on the details of interactions and flow of information within and outside the PCMH. Although further work is necessary to clarify the definitions of principles and attributes and to associate attributes with specific principles, this framework provides an approach to identifying the attributes of an existing PCMH and its potential for change.

Project Objectives:

• Conduct a comprehensive literature review into the various interactions a patient has within a patient-centered medical home. (Achieved)
• Convene an expert panel to obtain key stakeholder input on development of the PCMH information model. (Achieved)
• Convene working groups and focus groups for the purpose of model validation. (Achieved)
• Develop non-technical narrative and technical reports to describe the PCMH information model. (Achieved)

2011 Activities: Activities were focused on developing the information model and validating it through the expert panel, working groups, and focus groups. The project was completed in August 2011.

Impact and Findings: Through a series of nine patient scenarios, the project team constructed a common framework of what the PCMH is and is not, focusing on 44 of the 59 possible PCMH attributes that are thought to improve quality, lower cost, or differentiate the PCMH. The patient scenarios are used in the final report of the project to describe the potential interactions and information flows in a PCMH-supported health care ecosystem. These scenarios show how the shared PCMH principles can be realized using current resources and technologies, and how the principles should be continuously updated to reflect best practices as new technologies and approaches are added to the practice of medicine.

The scenarios are broken into the following categories:

• Interactions Focused on PCMH and Patient:
• Childhood Acute Illness
• Adult Acute Illness
• Adult Acute Illness (with different PCMH attributes)
• Interactions Focused on PCMH and Subspecialty Care:
• Childhood Acute Illness
• Adult Prevention
• Adult Chronic Disease
• Interactions Focused on PCMH and Inpatient Care:
• Young Adult Acute Illness
• Senior Chronic Disease
• Senior Acute Illness

Although the nine scenarios presented as a result of this project cover many of the attributes of the PCMH, the project team acknowledges that they do not describe all the information flows and interactions that characterize the PCMH. Further validation of the scenarios with providers and patients is warranted, and additional scenarios to refine the definition of the PCMH are needed. One of the limitations of this work is the lack of formal definitions of PCMH attributes in the literature. Obtaining consensus among the PCMH community on key performance indicators and goals of each PCMH attribute would facilitate evaluation of the scenarios and the extent to which they fully represent the PCMH attributes.

Target Population: Adult, Elderly*, Pediatric*, Teenager

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.