On December 8th, the first of a series of articles entitled “Continuity, Creativity, Consistency” was published in which we examined the role of The Less Initiative in SETMA’s past and its relevance to new requirements in healthcare delivery.  A more recent SETMA project is the Patient-Centered Medical Home (PC-MH) which further demonstrates the connection between SETMA’s past and present, and which fulfills the future demands the healthcare system is making upon healthcare providers.

In 2017 SETMA begins our ninth year of medical home learning and practicing.  Our pilgrimage toward PC-MH began in 1999 as a result of our study of Peter Senge’s The Fifth Discipline. In that study, SETMA identified ten principles which would guide our development in both our practice and in the electronic medical record (EMR) tool which we would design.  (see SETMA: May, 1999 - Four Seminal Events)  Ten years into our development, we realized that those ten principles were also the principles of PC-MH.

The Patient-Centered Medical Home Poster Child

In my morning clinic on February 17, 2009, I saw a patient whom I had seen in the hospital the previous Saturday and Sunday, He would soon earn the title of “SETMA's Medical Home ‘Poster Child’”.  In the hospital, he was angry, hostile, bitter and depressed. When he was ready to leave the hospital, I gave him an appointment to see me, even though he was not my patient. In his follow-up visit, his affect had not changed. In that visit, I discovered that he was only taking four of nine medications because of expense.  He could not afford gas to get the education he needed about his condition. He was genuinely disabled and could not work. He was losing his eyesight and could not afford to see an ophthalmologist. He did not know how to apply for disability. His diabetes had never been treated to goal.

When he left that visit on the 17th, he had an appointment to SETMA's American Diabetes Association-approved diabetes self management education program.  The fees for the education program were waived.  He also left with a gas card with which to pay for the fuel to get the education which was critical to his care. SETMA's staff negotiated a reduced cost with the patient's pharmacy and made it possible for the pharmacy to bill The SETMA Foundation. The patient's care included our assisting him in his application for Social Security disability. He had a visit that day with SETMA's ophthalmologist who arranged a referral to an experimental eye-preservation program in Houston, which was free.

Six weeks later, he returned for a follow-up visit. He had something which I could not prescribe for him; he had hope. He was smiling and happy. Without anti-depressants, or sedatives, he was no longer depressed as he now believed there was life after being diagnosed with diabetes for ten years. And, for the first time, his diabetes was treated to goal. 

In 2014, a summary of the first five years of his care in a medical home was summarized at Patient Centered Medical Home Poster Child: An Update after Five Years of Treatment in a Medical Home.  March 23-25, 2015, this couple was a part of an eleven-member team from SETMA which attended the Seventh Annual Medical Home Summit in Philadelphia, and which conducted a pre-conference seminar on Medical home and then made presentations during the conference.  (see Medical Home Summit THE SEVENTH NATIONAL - THE CONTINUING PURSUIT OF EXCELLENCE).  This month, December, 2016, I saw this couple in a routine follow-up clinic visit.  We reminisced about the soon to be eight years of our relationship and how well he is doing even with significant health issues.  There were smiles and laughter and hugs all around.

Back to the Beginning

The night of the above mentioned visit to SETMA’s clinic by “the Patient-Centered Medical Home Poster child,” February 17, 2009, a group of SETMA leaders attended a meeting in Houston, where the concept of PC-MH was discussed.  The organization which presented that lecture no longer exists.  At the end of the lecture, I asked, “If we are doing everything you say we must do in order to be a medical home, and we are, yet we know that we are not a medical home, and we aren’t, what must we do in order to become a medical home?”  They did not have an answer. 

On Wednesday morning, February 18, 2009, I sent the following note to SETMA’s leadership; it stated:   “Needless to say, I was ‘under whelmed’ by the presentation which we heard last night.  As I lay in bed last night thinking about the Medical Home, I got up and recorded a few thoughts some of which are below.  This begins to answer for me the issue which I raised last night.  If we accomplish what I have briefly outlined below and if we implement its use after fleshing it out so that it is comprehensive, I think we will take all of the elements of Medical Home, all of which we already do and we will create the synergy which Medical Home promises.  We are a very long way away, but this is a first step.” 

Beginning February 19, 2009 and for the next ten weeks, SETMA prepared a weekly article on the concept of medical home.  For the next ten weeks, SETMA’s understanding of medical home grew.  A review of those articles reveals that at first we simply commented on what others had said, but gradually, we began to create our own concept of PC-MH.  In this process, a healthcare executive with whom SETMA still works asked, “Is your medical home project just a passing thought, or are you committed to this method of healthcare delivery?”  My response was, “Time will tell.”

In 2009, 2010 and 2011, series of articles were published by SETMA on Medical Home:  see  Medical Home Series Two: Part XVIII - Introduction to SETMA’s 2009, 2010 and 2011 Series of Articles on Medical Home.  Over the next eight years SETMA would publish over 140 articles on PC-MH, all of which can be seen at Your Life Your Health - Medical-Home. 

Ultimately, SETMA would seek and receive recognition and/or accreditation from four medical-home accrediting agencies, but at this time, we only knew of one which was the National Committee on Quality Assurance (NCQA).

Continuity, Creativity and Consistency

In the context of “continuity, creativity and consistency,” 2017 will be the ninth year of our medical home pilgrimage.  As we begin that year, we hold recognition and/or accreditation by all four of the national agencies which offer medical home evaluation to medical practices.  And our accreditation extends from 2010 through 2019.  

The centrality of PC-MH to the future of healthcare is seen by the fact that in the Merit-Based Incentive Payment System (MIPS) created by Medicare Access and Chips Reauthorization Act of 2015 (MACRA) one of the four categories by which practices will be measured is “Clinical Practice Improvement Activity,” which is one-hundred percent fulfilled by NCQA Tier 3 Recognition, which SETMA has possessed from 2010 through 2019.

The role of PC-MH is also seen in my answers to questions posed by one of the PC-MH accreditation agencies for an upcoming publication.  The questions and my answers are as follows:

“What are the one or two trends and/or market forces for healthcare/physician networks for 2017, and what impact do you anticipate those trends and/or market forces to have?”

One trend is that in the face of geometric technological advances in healthcare techniques, increased emphasis must focus on rediscovering human values and human relationships as manifested in trust and dialogue between all participants in the healthcare dynamic 

The second trend is that as an extension of refocusing healthcare expenditures on quality, safety and outcomes, the market will demand the adoption of the elements and principles of PC-MH.  But that focus must not be in checking boxes but in dynamic collaboration. Unfortunately, MACRA and MIPS have systematized the deficiencies of the old system which will prevent true transformation. 

“What will be the biggest challenge and the biggest opportunity for healthcare/physician networks in 2017?” The biggest challenge is to understand that healthcare transformation is an organic outcome, resulting from the blossoming of the nurtured plant -- the organizational organism -- which springs from the nature of the patient-centered dynamic collaboration between healthcare professionals and healthcare participants. 

How Long Does it Last?

One of the measures of the value of innovation is “how long does it last,” and “how long is it effective in promoting and measuring quality of care?”  January 2017, SETMA enters our 23rd year of existence - personally, I enter my 44th year of medicine - as SETMA looks back on those early days, and as we see what has lasted, we are encouraged that the vision and aspirations we had in the beginning are still with us today.