The Patient-Centered Medical Neighborhood — Transforming Speciality Practice – NEJM

Transforming Specialty Practice — The Patient-Centered Medical Neighborhood — NEJM

The latest issue of the New England Journal of Medicine has an informative article on the ‘Patient Centred Medical Neighbourhood’.

The article reinforces the view of the Australian Centre for the Medical Home that the creation of a Medical Home is a necessary but not sufficient step in building a Person Centred Health System.

The authors explain that “term “medical neighborhood” has been coined to capture an expanded notion of patient-centered care, in which the PCMH is located (virtually or otherwise) centrally and is surrounded by specialty clinics, ancillary service providers, and hospitals”

They note that

“despite widespread reform of primary care practice, specialty practices have remained largely unchanged.
Many PCMH initiatives have wrestled with building effective partnerships with specialty practices that lack the capabilities and orientation to support care collaboration. ”

In a patient-centered medical neighborhood, specialty practices risk being relegated to the periphery, with patients’ access to them restricted by primary care providers, if the specialists do not embrace a more population-based approach and provide better value. The success of the medical neighborhood rests on alignment between the medical home and its neighbors in their long-term goals for their shared patient population.

Primary care cannot be the only point of leverage in any successful effort to control costs. “It requires the engagement of all physicians, primary care and specialist alike.”

Care coordination, particularly for elderly and chronically ill patients, remains a daunting task for primary care providers and a substantial barrier to improved efficiency and patient safety. The average primary care physician must coordinate care with 229 other physicians working in 117 practices.

Traditionally, care is considered to have been transferred to, rather than shared with, specialists when a referral occurs — a perception that results in fragmentation of care.

The authors conclude with several important precursors to effective medical neighbourhoods.

• First, a sound infrastructure design can connect PCMHs to the spectrum of surrounding specialty practices. An aligned information architecture will be vital to adequate patient access, care coordination, and communication.
• Second, a patient-centered neighborhood will rely on an organizational culture that supports shared learning and transparency of performance and cost data among participating practices.
• Third, payment incentives will have to be aligned around shared accountability for outcome and cost. Responsibility for outcomes and total cost of care will have to rest not only with primary care clinicians, but also with specialists who perform (often expensive) procedures and specialty services.