Is the Medical Home Approach Suited for the NP Role?

Article Outline

• Support for Medical Homes
• Rationale Against Medical Homes
• Copyright

Mary Anne Putt, FNP, APRN, received an MSN degree from Saginaw Valley State University and has been employed as a family nurse practitioner at Bay Regional Medical Center Family and Child Health Clinic/Family Practice Residency Program in Bay City, MI, for the past 7 years. Prior to becoming a nurse practitioner, she had 28 years' experience in the acute care setting, from working within a rural family practice clinic to being a consultant for persons with disabilities living in the community. She is an adjunct professor at Saginaw Valley State University, teaching within the family nurse practitioner program. Since 2004, she has volunteered at the Helen M Nickless Volunteer Clinic, serving individuals and families in mid-Michigan who have no health care insurance.

Sandra Wilbanks, APRN, MSN, FNP, has been a family nurse practitioner since 1999, with experience in internal medicine and adult and pediatric neurology and, currently, family practice in Sanford, MI. Most of her career as an NP has involved working with poor and underserved populations. She is an adjunct professor at Saginaw Valley State University, teaching within the family nurse practitioner program. She has also contributed the crossword puzzle for the Journal for Nurse Practitioners since February 2006.

The patient-centered medical home (PCMH) is a health care setting that facilitates partnerships between individual patients, their families, and their personal physician. Medical practices go through a voluntary recognition process by an appropriate nongovernment entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.

The physician has been the traditional leader of a team of individuals who take responsibility for the ongoing care of patients and, currently, there is much discussion on whether nurse practitioners are adequately prepared to be leaders of medical homes.

What is your opinion? To comment on this matter, email section editor Jacqueline Rhoads at jrhoad@lsuhsc.edu.

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Support for Medical Homes 

Mary Anne Putt

The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) developed joint principles of the patient-centered medical home (PCMH) in March 2007. The medical home is not a building, house, or hospital but rather an approach to providing comprehensive primary care for children, youth, and adults.

The concept behind the principle of the PCMH is based on continuity of care. Having one primary care provider (PCP) following an individual from birth to end of life allows for a holistic, patient-centered approach that focuses on those aspects in an individual's life that interfere with their wellness. Changing PCPs because of changes in health insurance coverage often results in repetitive work-ups, costly diagnostic testing, and redundant consultations with specialists. In PCMHs, care is coordinated across all elements of the health care system and the patient's community.

This concept is not new and has its roots in the family physician relationship of the past. The family physician usually lived and practiced in cities and towns across the country, often making house calls to meet his or her patients' needs. Caring for the entire family, and often the extended family, from childhood across the lifespan allowed for insight into those factors unique to individuals and families that might impact health. Individuals formed a life-long relationship with their family physician, becoming more comfortable in sharing very intimate details of their life.

A successful transition to this type of health care delivery now would depend on reimbursement for patient-centered care management outside of face-to-face services, as well as electronic medical record keeping, including patient-specific registries.

Some family practice offices have already initiated an open-access scheduling system that allows patients to be seen within 24 hours, eliminating unnecessary and costly visits to the emergency room.

Nurse practitioners are well positioned to serve as PCPs within the medical home system. Basic and advanced practice nursing education emphasizes the importance of the health and wellness continuum, stressing health education and preventive care through forming partnerships with patients and families.

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Rationale Against Medical Homes 

Sandra Wilbanks

The patient-centered medical home (PCMH) concept provides round-the-clock access to quality, comprehensive medical care. This is a goal that most of us have for all individuals, especially children. The idea is quite appealing, but there are barriers to achieving this goal. Providing this type of care is both financially challenging and time intensive. Many family practice offices are already overwhelmed, and this arrangement could require a significant amount of the office staff's time. The payment structure should reflect the value of the primary care provider and the office staff for work that falls outside of the face-to-face visit. As many of us who bill insurance companies know, compensation may be difficult to obtain.

The role of primary care provider (PCP) in the PCMH concept is well suited for an NP, but certain state limitations regarding ordering physical therapy or medical equipment could produce frustrating delays. Traditionally, a physician has been the provider to lead the medical home team and, in some areas, this stereotype may produce political barriers for nurse practitioners (NPs) to overcome. Significant physician involvement may be required, which would increase the expense of the plan.

Because this is a voluntary situation, not all areas are likely to provide these services to the community. It is possible that areas with severely limited resources, and underserved and underinsured populations would not offer the medical home option. Patients with low socioeconomic status are often in transient living situations, which complicates follow-up. This may limit medical home access to only the middle and upper classes and therefore miss the ones who may need it most.

An open-access scheduling system is ideal for the medical home concept but can present staffing challenges and wasted time if the slots do not fill up. It is also possible that families may begin to take the concept for granted and call for routine medication refills or requests during off hours, or become demanding. Finally, sharing medical information among many individuals increases the chance of infringing confidentiality.

Overall, the PCMH sounds ideal, but it may not be practical in our current health care system. More work and studies are needed to prove its value and feasibility.