In this second series of articles on Medical Home, we are reviewing what SETMA has learned since starting our pilgrimage to Medical Home in February, 2009. Having received National Committee for Quality Assurance (NCQA) Tier III Patient-Centered Medical Home recognition in 2010 and Accreditation Association for Ambulatory Heath Care (AAAHC) accreditation for Ambulatory Care and for Medical Home in August 2010 for one year and recertification in 2011 for three years, SETMA has continued to learn and to transform our organization into a "functioning" medical home.

Published in 2009, SETMA's Medical Home Series One is an eleven-part examination of what we were learning about Medical Home when we started this process. Those articles are posted below and under Your Life Your Health and can be found by clicking on the icon entitled, Medical Home.. Parts 1-IV of Series Two are:

• Part I - The Movie, July 7, 2011 - this reviews the Medical Home concepts which are seen in the 1951 movie, People Will Talk.
• Part II - The Sign Post, July 14, 2011 - this reviews the idea that Medical Home is a series of sign post along the avenue of life showing us how to maintain health and wellness and how to regain them, if we lose our health.
• Part III - The Baton, July 21, 2011 - this reviews the concept of "the baton" and of "the baton" posters in our lives. It reviews the foundations of SETMA's Medical Home which are found in our analysis and design of our practice beginning in 1995.
• Part IV - The Metaphor, July 28, 2011 - this reviews the metaphorical nature of the name "Medical Home" and its foundation principle of health and wellness.

Continuity of Care

Now, we come to Continuity of Care. Regardless of the standard of evaluation of a practice as a Medical Home - AAAHC (founded, 1979 and began accredited Medical Home in 2009), NCQA (founded 1990 and began recognizing Patient-Centered Medical Homes in 2009) URAC (formerly called the Utilization Review Accreditation Commission, founded 1991 and began accrediting Medical homes in 2011), or Joint Commission (formally called the Joint Commission on Accreditation of healthcare Organizations and abbreviated as The Joint Commission was founded in 1951 and began accrediting Medical Homes in July, 2011) - the establishment, support and maintenance of continuity of care is critical to its definition and function

The elements of continuity of care are:

1. Data connection and data sharing over the entire healthcare experience of the patient whether that involves different visits with the same provider, care by multiple providers, multiple locations of care, or multiple disciplines of care such as physicians, nurse practitioners, physical therapist, social workers, nutritionists, hospices, home health, case managers, pharmacists, etc.
2. Uninterrupted care of and attention to an acute or chronic problem until it is resolved or stabilized. This means that follow-up care always includes review, evaluation of and needed adjustments to previous care.
3. All care givers having adequate knowledge of a patient's overall health and of all conditions requiring attention. The association of continuity of care with the patient being seen by the same healthcare provider assumes that the same provider can and does know more about the patient than a new or different provider, depending upon the quality and granularity of the patients health record that may or may not be the case.
4. The foundation of the patient's care is a record which is longitudinal, cumulative, granular, accurate, accessible, available, confidential and thorough. Electronic patient records is the only method of medical-record keeping which can build on previous examinations and evaluations, continually transforming the "picture" of the patient from a silhouette, longitudinally into a true, granular portrait of the patients health and person.
5. All members of the healthcare team know the patient and have a personal interest in the patient's health and welfare. While the concept of medical home currently depends heavily upon a patient's identification of a "personal healthcare provider" as the principle conduit of continuity of care, the concept also recognizes the healthcare team as an essential foundation for the improved care given in the medical home. An essential part of the development of the medical-home model will be the clarification of the tension between care by a personal provider and care by a healthcare team.
6. Effective transitions of care are established and they function to transfer care from one point of care or provider to another provider or point of care. Transitions of care will be dealt with later in this series but they are critical to the maintaining of the continuity of care when the patient moves from one venue of care, i.e., inpatient hospital, to another, i.e., outpatient or ambulatory care. Like the universal joint in an automobile power train, the transition of care allows for the power, the standard of care and the content of care, created by and in one venue of care to be incorporated into and to be maintained in another venue..
7. The patient is included as a critical member of the medical home team. All other members of the team respect and support the autonomy, confidentiality and priority of the patient in decision making and in executing the medical home's plan of care and treatment plan. This requires that enhanced communication be present between the patient and provider including secure web portals, health information exchanges, telephone communication and after-hours access to care.

Tension between the personal healthcare provider and the healthcare team

All accrediting and recognition agencies for Medical Home associate continuity of care with the person of a healthcare provider, requiring that every effort be made to see that the same provider see the patient each time. At SETMA, we track this information and 61% of the time we fulfill this goal.

The American Academy of Family Practice (AAFP) defines Continuity of Care as:

"...the process by which the patient and the physician are cooperatively involved in ongoing health care management toward the goal of high quality, cost-effective medical care."

Continuity of care is a hallmark and primary objective of family medicine and is consistent with quality patient care. The continuity of care inherent in family medicine helps family physicians gain their patient's confidence and enables family physicians to be more effective patient advocates. It also facilitates the family physician's role as a cost-effective coordinator of the patient's health services by making early recognition of problems possible. Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient's history from experience and can integrate new information and decisions from a whole-patient perspective efficiently without extensive investigation or record review." (Emphasis added)

The phrase "knows the patient's history from experience," reflects the Medical Home accreditation agencies' ideal that "continuity of care" principally takes place through the person of a particular and previously identified healthcare provider with whom the patient has a relationship. As will be discussed below, in SETMA's judgment, this is increasingly becoming an inadequate understanding of the process of medical home and of continuity of care.

The AAFP's definition of "continuity of care" concludes with its association with "coordination of care."

"Continuity of care is facilitated by a physician-led, team-based approach to health care. Thus, the American Academy of Family Physicians supports the role of family physicians in providing continuity of care to their patients in all settings, both directly and by coordination of care with other health care professionals."

In the Medical Home, the team leader is the personal provider, while care is provided by a team. As more accrediting agencies enter the Medical Home arena definitions change. The Joint Commission also accredits Medical Homes operated exclusively by Nurse Practitioners while the 2009 version of NCQA's Medical Home standards did not recognize Nurse Practitioners as team leaders in Medical Home but do so in their 2011 standards. Standards are evolving and changing as we all learn more about Medical Home.

The AAFP's policy statement on Medical Home states:

"The (AAFP) believes that everyone should have a personal medical home that serves as the focal point through which all individuals-regardless of age, sex, race, or socioeconomic status-receive acute, chronic, and preventive medical services. Through an on-going relationship with a family physician in their medical home, patients can be assured of care that is not only accessible but also accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians. (2006) (May 2011 Board)"

In reality, of all of the elements of "continuity of care" only one is related to a personal relationship with a particular provider. While few things in medicine are as enjoyable as a personal relationship over a long period of time with a patient and with multiple members of the patient's family, the quality of care is driven far more significantly by an accurate, thorough and available electronic health record.

This is demonstrated by SETMA's experience with its expanding use of the EHR. When SETMA began using the EHR in the hospital to complete the Admission History and Physical Examination and then the Discharge Summary, we developed the ability to complete daily progress notes in the hospital. (As will be discussed later, the name of the discharge summary has been changed to Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan. This name change relates directly to the function of this document as the principle vehicle for effective Transitions of Care.)

In August of 2007, one provider in SETMA used the inpatient, daily-progress note function for over 2,500 daily hospital visits. While the hurdles of sharing critical data made this function labor intensive, it also had enormous value. Some of that value related to continuity of care. The benefit was seen in:

• Comprehensive documentation of a patient's inpatient care.
• Continuity of care - follow-up of inpatient care in the outpatient setting is dependent upon the availability of the inpatient record in the outpatient setting and is also dependent upon the completeness of that inpatient record.
• Cost savings realized when the inpatient record and outpatient record are in the same data base, eliminating redundant care and making it possible to schedule appropriate outpatient follow-up without extending a hospital stay just to make sure something gets done.
• Completion of the patient's "electronic" healthcare portrait, as now ALL patient encounter information is integrated into a single data base whether Nursing Home, In-patient Hospital, Out-patient hospital, Clinic, Physical Therapy or Home.

Documentation of a patient's care in the hospital should contribution to the portrait of that patient's health.  Sometimes for a variety of reasons that portrait is more like a silhouette.  As a silhouette, the medical record accurately depicts the outlines and contours of a patient's health, but is not a granular, detailed, specific and precise picture of the patient's health status.  This tool (the Electronically produced Daily Progress Note) - and it is only a tool - when fully developed will allow for a dynamic portrait to grow throughout the patient's hospitalization, such that by the time the patient leaves the hospital, the portrait will be complete and it will have evolved over the entire hospitalization.

Patterns of Change Rather than Static Snapshots

In a piece on "Clinical Inertia," which SETMA contributed to HIMSS' Quality 101 website, the power of the EHR to produce a patient portrait is addressed. In his book, The Fifth Disciple, Dr. Peter Senge, summarizing systems thinking, almost seems to have healthcare in mind. He describes systems thinking as, "a discipline of seeing wholes...a framework for seeing interrelationships rather than things, and patterns of change rather than static 'snapshots.'" Historically, medical records have been silhouettes of a patient's condition with little connection between the past and the future. Electronic Health Records (EHR) has changed that, or at least EHR has the potential of making that changing. With the cumulative data capacity of EHR, which provides a longitudinal portrait of the patient, patterns of change can be viewed seasonally and progressively.

The application of these concepts to medicine provides an elegant framework with which to study the design of the tools used to effect change in behavior of patients and physicians, and to shift the focus from information and experience to evidenced-based outcomes and data analysis over time. The most significant shift of mind in healthcare requires that the patient be seen as a whole and this requires a different kind of medical record than was found in the 18th, 19th and 20th centuries.

Continuity of Care is a central focus of patient-centered medical home because it requires and allows the patient to be seen as a whole person and it requires and allows for the patient's care to be seen as a continuum rather than as unrelated episodes. Our understanding of continuity of care will evolve over time and the processes to create and maintain continuity will also mature. What we know now is that it is critical to excellent care in the medical home.