We haven’t published on medical home research for a while. The concept was very hot a few years back and a number of institutions adopted the so-called patient-centered medical home model, which supposedly improves primary care and coordination of all medical services, with a resulting increase in quality and decrease in spending. Research results so far have been mixed and maybe not always of the best methodological quality. The new research was performed in regard to the Veterans Administration’s medical home model and took a look at results over a long period of time. (JAMA Article) The medical home project began in 2010 at the VA and earlier research had found inconsistent implementation but that clinics with better implementation had lower rates of ER use and ambulatory care-sensitive hospitalizations, but no change in all-cause admissions. This study examined a longer period and attempted to correlate degree of compliance with PCMH standards with changes in utilization. The ideal patient-centered medical home meets a series of defined structural and process standards in eight domains around delivery of care. The researchers assigned a score for each VA primary care clinic in regard to how well they met those standards and tracked changes in that score over the study period. They looked at two cohorts of veterans; those under age 65 and those over age 65 and in fee-for-service Medicare. Veterans often use the VA system and the community-based health system, so getting a complete look at their utilization is important.
The primary outcomes were ER visits, overall hospitalizations and ambulatory care-sensitive ones. The analyses were conducted on a patient-adjusted basis to make clinic populations comparable in demographic, health status and other characteristics. There were over a million patients in each of the two study groups. There was no consistent association between changes in a clinic’s score on patient-centered medical home implementation and the primary outcomes. For the group under age 65 there was some minimal association with ER use. Patients at clinics whose scores improved over the study period had fewer ER visits than those patients at clinics whose score didn’t change, but the same was true for patients whose clinics’ scores got worse. Hard to know how to interpret that. And in the over age 65 group, a worsening PCMH score was actually associated with fewer ER visits and all-cause hospitalizations. Since you would like to believe that over time, a clinic would get better at being a PCMH, it is disappointing that not only did some clinics get worse, but that this worsening didn’t seem to matter for some utilization outcomes. Hard not to conclude that maybe meeting all those patient-centered medical home requirements doesn’t actually do anything to improve care.