Program Goals

As defined by the Institute of Medicine, patient-centered care is "health care that establishes a partnership among practitioners, patients, and their families (when appropriate), to ensure that decisions respect patients' needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care." In primary care, such care is best provided in a medical home—a primary care practice or health center that ensures patients have enhanced access to their clinicians (for example, through the availability of evening or weekend appointments), coordinates care, and engages in continuous quality improvement.

The goal of The Commonwealth Fund's Patient-Centered Coordinated Care Program, established in 2005, is to improve the quality of primary care by making it more patient- and family-centered. The initiative supports projects that:

• promote the collection of information on patient-centered care and the delivery of care to facilitate public reporting and quality improvement;
• stimulate adoption of effective practices, models, and tools to make primary care practices patient- and family-centered; and
• improve policy to encourage patient- and family-centered care in medical homes.

Selected Projects

Medical Home Demonstration and Evaluation. Individual components of the medical home have been associated with a number of positives—higher-quality care, lower costs, and higher satisfaction for patients and practice staff, among them—but there have been no evaluations of the model as a whole. In April 2008, the Fund awarded a grant to Qualis Health in Seattle to run a five-year medical home demonstration project that seeks to transform 68 safety-net primary care clinics within five regions of the United States into patient-centered medical homes that achieve benchmark levels of quality, efficiency, and patient experience. In the project's first year, Qualis Health president and CEO Jonathan Sugarman, M.D., in partnership with Ed Wagner, MD, of the MacColl Institute for Healthcare Innovation and their teams, developed change concepts, convened a panel of experts to provide guidance, and generated awareness of the initiative among potential stakeholders. Following a request-for-proposals, the team selected five regions for participation: Colorado, Idaho, Massachusetts, Oregon, and Philadelphia.

The Commonwealth Fund is joined in support of the project by eight co-funders, including the Colorado Health Foundation, Jewish Healthcare Foundation (Pittsburgh), Northwest Health Foundation (Portland, Oregon), Partners HealthCare (Boston), Blue Cross Blue Shield of Massachusetts Foundation, Blue Cross of Idaho, The Boston Foundation, and Beth Israel Deaconess Medical Center (Boston).

Marshall Chin, M.D., and a team of researchers at the University of Chicago were awarded a Fund grant to evaluate whether the participating clinics, in fact, become medical homes; how medical homes affect quality and efficiency; and what factors are associated with a clinic's successful implementation of this care model.

Evaluating the Patient-Centered Medical Home. In addition to the evaluation of the Safety Net Medical Home Initiative, rigorous intervention studies are needed to build an empirical basis and solid foundation for the medical home concept, as well as to assess the viability of implementation. To date, The Commonwealth Fund has played a leadership role in defining the medical home concept and evaluating the most promising demonstrations. The Commonwealth Fund is supporting several evaluations of medical home demonstrations that are under way . Using qualitative and quantitative methods, the research teams will seek to determine:

• whether physician offices are able to make the changes necessary to function as medical homes; and
• whether physician offices that receive technical assistance and a revised payment structure improve their performance on measures of quality, efficiency, patient experience, and physician and staff satisfaction.

The investigators have agreed to collaborate to ensure standardization of data collection instruments and consistency in outcome measures. This will facilitate future comparisons of results for provider and policy audiences.

Measuring the Delivery of Patient Care. With Commonwealth Fund support, the National Committee for Quality Assurance (NCQA) has worked with the nation's leading primary care specialty societies to develop practical criteria for assessing and recognizing physician practices as patient-centered medical homes. NCQA has incorporated 18 patient-centered care measures into the standards for its Physician Practice Connections–Patient-Centered Medical Home program. Supported by a subsequent Fund grant, Sarah Scholle and her colleagues are developing and testing additional medical home measures related to the quality of patient–physician communication, family and community involvement in care, patient self-management and care coordination.

Promoting Effective Practices, Models, and Tools. Becoming a patient-centered medical home also requires a degree of transformation on the part of the individual primary care practice. That is one of the seminal lessons drawn by Commonwealth Fund–supported researchers at the University of Texas Health Sciences Center at San Antonio. Led by Carlos Jaén, M.D., Ph.D., the research team surveyed patients served by the 36 physician practices taking part in the American Academy of Family Physicians' TransforMED demonstration, which is testing a new patient-centered care model. Participating practices are implementing a comprehensive set of innovations to improve health care quality, safety, efficiency, patient-centeredness, access to care, and information systems.

In a paper published in the journal Family Practice Management, Jaén and colleagues laid out simple strategies, based on the survey findings, to help physicians structure office visits to ensure that patients' concerns are addressed, and that clinicians and patients are in agreement at the end of the visit about the next steps in the care plan.

Assessing Payment Options. What will it cost practices to become medical homes? A project jointly sponsored by The Commonwealth Fund and the American College of Physicians (ACP) is seeking to answer that question, and to develop payment options that would support medical home adoption.

As part of their research, Robert Berenson, M.D., of the Urban Institute is visiting primary care practices and working with organizations representing employers, payers, and consumers, as well as physicians. Berenson hopes the information yielded by their study will help insurers and policymakers understand the cost associated with delivering care in a medical home and options for how providers could be compensated to sustain and encourage how providers should be compensated for delivering the comprehensive care associated with the medical home. In a 2008 article in Health Affairs, Robert Berenson, M.D., discussed the multifaceted challenges physician practices face in implementing the medical home model—among them, management capability, physician leadership, and an ability to develop processes and information technology systems.

Medical Homes in Medicaid. Given the growing interest in medical homes for Medicaid populations, state Medicaid officials require guidance in implementing medical home models and designing the requisite payment systems.

To assist states, Neva Kaye and the National Academy for State Health Policy (NASHP) are working with state Medicaid officials to inform policymakers of the benefits of patient-centered medical homes, promote financing and policy options for implementing them, and track states' implementation efforts.

In 2008, NASHP provided technical assistance to Medicaid and state officials from eight selected states—Colorado, Idaho, Louisiana, Minnesota, Oklahoma, Oregon, New Hampshire, and Washington—on ways to advance the medical home model in their states. In particular, NASHP identified promising options for how state Medicaid programs could change reimbursement policy to support medical homes, create a state infrastructure to encourage implementation, and collaborate with public and private payers in medical home demonstrations. The lessons from working with these states are described in a Commonwealth Fund/NASHP report from June 2009.

Future Directions

The Commonwealth Fund plans to continue to test the patient-centered medical home, particularly in safety-net practices and settings where patients with chronic conditions receive care. Evaluations of medical home demonstrations will provide objective information about the impact on clinical quality, the experiences of patients and physicians, and the costs of care. And lessons gleaned from successful medical home models will help insurers, policymakers, and others promote the medical home as the new standard of primary care.

To apply for a grant from the program, visit the Applicant and Grantee Resources page.