Because it appears likely that this model is here to stay in some form, it behooves us to consider, with our knowledge of systems and process redesign, how we can take the Medical Home model to the next level—one where we have successfully integrated specialty care. There is a dearth of information about next steps. Fisher and others have coined the term “medical neighborhood,” implying that the specialists would be a “neighbor” of the Patient Centered Medical Home.36 The designation of a neighbor does not specify the relationship. A neighbor can be someone you may or may not like; you might not invite them to your next party and, when in need, you may either borrow a cup of sugar from your neighbor or you can go to the store. In a neighborhood, the specialist could have a limited or inadequate role, relegated to involvement in patient care only at the behest of the Patient Centered Medical Home. This role is reactive rather than proactive. A more fitting analogy for a new relationship may be the formation of a co-op in which we specialists and our colleagues in primary care work together and are both invested in the efficiency, effectiveness, and outcomes of patient’s and disease populations’ care.
Instead of trying to derail the train, a more effective approach may be to morph the current model into a next iteration. Figure 2 (above) provides some key areas that need to be defined in this new model, including:
- Trigger for Specialty Care: How do we move from a manual process of placing a consult, to a proactive, data-driven approach?
- Mode of Care: How do we move beyond the traditional face-to-face consult to other means of delivering care (such as telemedicine and provider–provider off-line management)?
- Care Pathway: How do we move from gestalt-driven hyper-variable care to using functional and outcome measures and pathways of care with defined roles and responsibilities?
- Communication: How do we move from the phlegmatic communication process where there is a high “noise-to-signal” ratio (a lot of meaningless content, with resulting inability to see what actually needs to be done) to a process that establishes communication guidelines that facilitate transitions and handoffs of care?
Implementing the primary care Medical Home presents daunting problems. Most importantly, we believe that this model in its current form represents an inadequate solution for reducing the costs and improving the outcomes of chronic disease care. In contrast, we propose that integrating this necessary care through system-based accountable programs can be achieved by realigning existing resources and using tested approaches to produce immediate short-term and increasing long-term benefits. Continuous process improvement and industrial work management methods are ideally suited to testing, implementing, and disseminating these positive changes.