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The DNP and the Healthcare Home

DNP graduates are in a position to enhance care in this new model.

The infrastructure on which the American healthcare system rests is under tremendous strain. People are without healthcare coverage, medical waste is at an all-time high, access to care is limited, and providers are overburdened. It's going to take a complete overhaul to transform and redesign our current healthcare system to an epic patient-centered reality. The patient-centered healthcare home model of care has a potential to restore the nation's healthcare and redirect the focus toward a team approach (see figure).

History

In 1967 the American Academy of Pediatrics (AAP) introduced the term "medical home" as a model to care for children with chronic health needs.1,2 By 2002 the AAP recognized that modifications were necessary and principles such as integrated care, informational technology, quality and safety, and accessibility were adopted.1 Redirection from a physician-led approach to a patient-centered team approach was unfolding. In 2004 the American Academy of Family Physicians (AAFP) adopted the concept for their Future of Family Medicine project and the American College of Physicians released the first primary care medical home report in 2006.2 The move toward using the healthcare home model to care for all ages was underway. Today the concept is being studied closely by both physician and nurse practitioner led teams to determine the quality and cost benefits as a new era of healthcare for Americans unfolds.

Definition

Although it seems straightforward, there is no standard definition of a healthcare home. According to the AAFP, their definition of a "patient-centered medical home" involves the patient becoming accountable for their own health and well-being as they are led by a medical team.3 There is an ongoing relationship between the patient and provider to provide continuous and comprehensive care.2 This requires broad change in all dimensions to arrive at patient-centered care. Most will agree that certain elements, attributes or principles are required to function at the level of a healthcare home. These include engaged patients and families, accessibility, quality driven and evidence-based care, sustained personal relationships, holistic care, a culturally sensitive focus, interprofessional collaboration on care plans, scheduling modifications, medication coordination, community outreach, informational technology/electronic medical record, and reimbursement reform.4-6

Some guiding principles of the healthcare home are as follows:

  • Care must be patient focused, a partnership that not only involves the patient in their own care but includes family preferences, values and culture. The Agency for Healthcare Research and Quality (AHRQ) believes the patient becomes the core of his or her own personal healthcare plan by deciding at what level they would like to manage and organize their own healthcare.7
  • Comprehensive care is a facet of the healthcare home that involves meeting the patient's needs through holistic care. This is attainable through well-rounded medical teams of physicians, nurse practitioners, physician assistants, pharmacists, nutritionists, social workers, clergy, educators, care coordinators, and information technology specialist.7,8
  • Urgent healthcare needs must be met in a timely fashion through face-to-face contact, 24 hour phone service, and advanced electronic technology (email, texting or telehealth). Appointments for both primary and specialty care must be within 24 to 48 hours to accommodate the patient's acute needs.
  • Quality and safety are realized through the use of evidence-based medicine, the use of clinical decision-support tools, and patient and family performance measurements.7,8 This demonstrates a commitment to meeting quality and safety benchmarks, especially if the data measurements are made public.

Source: http://pcmh.webexone.com
Some specific strengths of the healthcare home include the following:

  • Although evidence is in its premature stages, it does reveal that healthcare homes deliver higher quality care at a lower cost, especially related to chronic care.5 The most recent ambulatory medical care utilization estimates show that 1.2 billion visits were made to physician offices, hospital emergency departments and outpatient departments in 2007.9 Of these, only 48% were made to primary care physicians.9 This data exhibits that patients are visiting medical providers other than their primary care providers which can lead to inconsistency and increased medical care costs. Additionally, only one half of patients understand the plan of care from their provider due to the visits being too short to address their health concerns.10 The healthcare home can potentially improve this.
  • The healthcare home places the patients' needs first and improves the patient experience.
  • Preliminary results of studies done by the Veterans Affairs Administration (VA) and other organizations on the cost containment associated with the healthcare home reveal millions of dollars in cost savings.2

The healthcare home does have its weaknesses, and among them are the following:

  • It is not only challenging to implement the necessary technology but also extremely costly. The VA expects it will cost $250 million to transition its clinics electronically to the healthcare home model over 5 years.10
  • The process of converting to a healthcare home takes years and can increase workload. Change fatigue can have detrimental effects on the patients, staff and finances of a practice.6 The National Committee for Quality Assurance (NCQA) predicts it will take three or more years to successfully implement the healthcare home model of care before benefits and financial gains are established.6
  • Forty percent of the workload (referrals, completing forms, emotional support, and outside methods of communication with patients) in primary care is not reimbursed.2 This creates confusion and controversy over how to properly reimburse care in a healthcare home. Several models have been proposed to accommodate these reimbursement dilemmas, such as fee-for-service, per member or per month fees, or pay-per-performance fees, which all have unique challenges.2
  • Variance in defining the healthcare home has caused patient confusion and a connotation of institutionalized care or nursing home care.10,11 Educational efforts and communication initiatives are critical in the quest to clearly define the healthcare home concept so that public is made aware of the quality, coordination and patient-centered approach involved.
  • Practice transformation is another area that lacks the universal language. The NCQA has taken the lead with recommendations for a three-tiered implementation process that includes 30 elements, of which 10 are mandatory.6,10 The mandatory areas include access and communication, patient tracking and registry, care management, patient self-management support, test tracking, referral tracking, and performance reporting and improvement.10
  • Measurement of healthcare home outcomes is not standardized. Current standards of measurement have been criticized for exaggerating information technology and underemphasizing the healing process.11 This makes it challenging to measure the goals supported by the healthcare home. It is important for the public to have access to these performance reports when deciding where to obtain care and how to choose providers who deliver high quality, patient-centered care.
  • Sixty five million Americans live in areas designated as primary care shortage areas.10 Increases in staffing ratios to devise medical teams will only add to the current shortages.12 Training efforts for healthcare providers need to focus on team perspectives, electronic health records, leadership, and quality improvement to prepare staff for their new roles.12

Healthcare Homes and the DNP Role

An estimated 30% increase in U.S. medical school enrollment would be needed for the physician population to meet the population growth, aging and other healthcare factors that the United States faces.13 This equates to a shortage of 124,000 physicians by the year 2025.13 Moreover, the population is projected to grow by more than 50 million between 2006 and 2025 to 350 million.13 When universal healthcare is added to the above equation shortages, we are now an additional 31,000 providers short.13 As the primary care specialty continues to fade and demand increases, it opens the door to nurse practitioner-led healthcare home teams. This does not come without resistance from medical bodies and regulatory policy makers who have their own language about defining the healthcare home team. Organizations like the AAFP, American College of Emergency Physicians, NCQA, and the Patient-Centered Primary Care Collaborative encourage terms such as personal physician, primary care physician or physician responsible for ongoing care.14 The National Association of Pediatric Nurse Practitioners actively seeks provider-inclusive terminology.14

Another hurdle facing advanced practice nurses is that many states do not allow nurse practitioners to practice without a collaborative agreement and several states still do not allow NPs or PAs to prescribe controlled substances. This makes it quite difficult to deliver quality care, especially to those with chronic illnesses living in inner-city and rural communities. Attitudes that exclude NPs and PAs must change in order for patients to obtain comprehensive care in the truest sense of the healthcare home model of care.

The focus of care needed in rural and inner-city settings will only increase and the demand for providers will continue to be a challenge. The need for nurse practitioners to help fight the aliments of infection plagued by poverty in the inner-cities is of great demand. Recruitment and commitment to vulnerable and at-risk populations will be essential to the health of this nation. Educating nurse practitioners at the DNP level allows for improvement in provider care to meet these needs. DNP-prepared NPs will be better equipped to fight politically for their scope of practice at local, state and national levels. The leadership and interprofessional collaboration attained will allow NPs to care for patients with more chronic issues through their practice-oriented degree. DNP-prepared nurses may foster other nurses on their journey to advancing their education. Preparing advanced nurses not only takes less time than medical school, but is just as effective in the delivery of care to serve this needed population of growth. The DNP emphasis on primary care and its streamline clinical focus promotes itself as a solution to lead the way for healthcare homes and the future of healthcare.

Conclusion

Initially healthcare homes were used in the care of chronically ill pediatric patients. As the concept has evolved, it claims to be the champion of comprehensive, quality-driven care at a fraction of the cost involving all ages. This presents challenges as various definitions and dimensions exist. Not to mention the primary care transition is a complex redesign involving time, money, fatigue and provider power. It is based on integrated core principles that have their own advantages and disadvantages to both the patient and medical team. As America redesigns the infrastructure upon which the U.S. healthcare system stands, it is of the utmost importance to find a sophisticated solution. Careful consideration must be taken to keep the patient as the number one priority. There is no better time than the present for DNP graduates to apply leadership skills, interprofessional collaboration, policy change, health information technology and evidence-based practice to rebuild the crippled U.S. healthcare system.

Michelle Papachrisanthou is a pediatric nurse practitioner and doctor of nursing practice student who works at Belleville Pediatrics & Adolescent Medicine in Belleville, Ill.

References

1. Bolin JN, et al. Patient-centered medical homes: Will health care reform provide new options for rural communities and providers? Fam Comm Health. 2011;34(2):93-101.

2. Rosenthal TC. The medical home: Growing evidence to support a new approach to primary care. J Am Board of Fam Med. 2008;21(5):427-440.

3. American Academy of Family Physicians. Patient-centered medical home, definition of. http://www.aafp.org/online/en/home/policy/policies/p/patientcenteredmedhome.html. Accessed March 12, 2012.

4. Barr MS. The patient-centered medical home: Aligning payment to accelerate construction. Med Care Res Rev. 2010;67(4):492-499.

5. Nutting PA, et al. Transforming physician practices to patient-centered medical homes: Lessons from the national demonstration project. Health Aff. 2011;30(3):439-445.

6. Nutting PA, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254-260.

7. Agency for Healthcare Research and Quality. Defining the PCMH. http://pcmh.ahrq.gov/portal.server.pt/community/pcmh_home/1483/PCMH_Defining%20the%20PCMH_v2. Accessed April 10, 2011.

8. Meyers D, et al. Health information technology: Turning the patient-centered medical home from concept to reality. Am J Med Quality. 2011;26(2):154-156.

9. Centers for Disease Control and Prevention. Ambulatory medical care utilization estimates for 2007. http://www.cdc.gov/nchs/data/series/sr_13/sr13_169.pdf. Accessed March 19, 2012.

10. Cassidy A. Patient-centered medical homes: A new way to deliver primary care may be more affordable and improve quality. But how widely adopted will the model be? Health Aff. 2010; 9-14-10 Health Policy Brief:1-6.

11. Rittenhouse DR, Shortell SM. The patient-centered medical home: Will it stand the test of health reform? JAMA. 2009;301(19):2038-2040.

12. Reid RJ, et al. The group health medical home at year two: Cost savings, higher patient satisfaction, and less burnout for providers. Health Aff. 2010;29(5):835-843.

13. Dill MJ, Salsberg ES. The complexities of physician supply and demand: Projections through 2025. http://www.innovationlabs.com/pa_future/1/background_docs/AAMC%20Complexities%20of%20physician%20demand,%202008.pdf. Accessed March 15, 2012.

14. Vest JR, et al. Medical homes: "Where you stand on definitions depends on where you sit." Med Care Res Rev. 2010;67(4):393-411.


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