J Am Board Fam Med
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Comparative Study
Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home.
Health care reform requires major changes in the organization and delivery of primary care. In 2003, the University of Utah Community Clinics began developing Care by Design (CBD), a primary care model emphasizing access, care teams, and planned care. In 2007, leading primary care organizations published joint principles of the patient-centered medical home (PCMH), the basis for recognition of practices as PCMHs by the National Committee for Quality Assurance (NCQA). The objective of this study was to compare CBD and PCMH metrics conceptually and statistically. ⋯ Practice redesign requires an ability to assess uptake of the redesign as a transformation progresses. The correlation of CBD and PCMH is substantial conceptually but low statistically. PCMH and CBD focus on complementary aspects of redesign: PCMH on structure and CBD on process. Both domains should be addressed in practice reform. Both metrics are works in progress.
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New Zealand (NZ) has a central government-driven, tax-funded health system with the state as dominant payer. The NZ experience precedes and endorses the US concept of patient-centered medical homes providing population-based, nonepisodic care supported by network organizations. ⋯ Key elements include enrolled populations; an interdisciplinary team approach; health information technology interoperability and access between all providers as well as patients; devolution of hospital-based services into the community; intersectorial integration; blended payments (a combination of universal capitated funding, patient copayments, and targeted fee-for-service for specific items); and a balance of clinical, corporate, and community governance. In this article, we discuss reforms to NZ's primary care arrangements over the past 2 decades and reflect on the lessons learned, their relevance to the United States, and issues that remain to be resolved.
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Many primary care practices are currently attempting to transform into patient-centered medical homes (PCMHs), but little is known about how patients view aspects of the PCMH or how they define patient-centeredness. ⋯ Our patients want a provider to know them personally and to take time to listen to their issues. They feel that they cannot access their providers in a timely fashion, find our automated phone systems frustrating, and want more time with their provider. Although the technological and structural implementation of the PCMH requires considerable effort and resources, we cannot neglect the relationships we have with our patients. Patients should be involved in this process of change to ensure we address their concerns and preserve the primary care relationships they value.
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Patients with complex behavioral health and medical problems can have a disproportionate impact on emergency departments. ⋯ Team-based drop-in group medical appointments coupled with case management seem to be a cost-effective model to reduce emergency department visits by some patients with complex behavioral health and medical needs.
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Since 1948 health care in the United Kingdom (UK) has been centrally funded through the National Health Service (NHS). The NHS provides both primary and specialist health care which is largely free at the point of delivery. Family practitioners are responsible for registered populations of patients and typically work in groups of 4-6 self-employed physicians. ⋯ These reforms have been associated with some major improvements in quality, including improved chronic disease management and reduced waiting times for specialist care. The four countries of the UK differ in some important aspects of health care organization: proposed reforms in England would move towards a more market-driven system, with family practitioners acting as payers for specialist care and controlling 70% of the NHS budget. The other countries (Scotland, Wales and Northern Ireland) focus more on trying to create area-based integrated systems of care.