Tuesday, May 24, 2011

More On The Synergies Between the Patient Centered Medical Home (PCMH) and Remote Telephonic Disease Management

One criticism of the Patient Centered Medical Home (PCMH) is that its officially endorsed definition is operationally vague.  While organizations such as the NCQA and URAC have developed detailed specifications, it's still possible to meet a minimal number of them with varying degrees of implementation and still claim official credit as a PMCH.  That lack of preciseness not only leads to the PCMH meaning different things to different people, it also makes it difficult to include it in a defined insurance benefit or craft supporting legislation.  Even the PCMH's supporters agree that the PCMH is unfinished and still needs to evolve.

With that as background, suppose the Disease Management Care Blog described a new PCMH arrangement, where a third party conducted a mass recruitment and education campaign consisting of a mailing over a PCMH physician's signature, followed by phone calls from non-physician educators?  While that classic "disease management" approach might be familiar to many DMCB readers, it probably would also run afoul of chronic tensions underlying the "ownership" of all the team-based elements that make up the PCMH.  Accordingly, will the continuing evolution of the PCMH ever lead to the inclusion of remote telephonic care management?

According to PCMH advocate Thomas Bodenheimer's editorial in the latest issue of the Archives of Internal Medicine, the answer is now "yes."  Likening the PCMH to a diaphanous "Holy Grail," he argues its concept now allows for the assignment of routine and chronic care tasks to non-physician care coaches working within "teamlets" linked to the larger collaborative teams with physician oversight.  He says that can help physicians refocus on all patients instead of just those with appointments while "delegating" care tasks to non-physicians.  If physicians can do this, he implies, the Holy Grail will finally be found and medical care will become righteous and pure.

And what is the basis for Dr. Bodenheimer's conversion?  His editorial is in response to a published study by Karen Lasser and colleagues appearing in the same issue of the Archives.  465 patients cared for in 15 Boston community centers who had no record of colon cancer screening were randomly assigned to usual care vs. a mailing combined with "centrally" based "navigators who made as many as 11 attempts to telephone their patients and engage them in the cancer screening.  After one year, 34% of the intervention patients vs. 20% of the control patients had screening, difference that was statistically significant.

In the Lasser study, the navigators were not located in the 15 clinics, were trained separately and work autonomously. This introduces a "virtual" dimension to the PCMH that is similar to traditional disease management programs. The DMCB doubts the physicians in the 15 clinics really cared all that much, just so long as more patients got the care they deserve. 

It appears Dr. Bodenheimer supports that assessment and agrees that remote telephonic support by non-physicians is a good thing for the still evolving PCMH.

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