Organizing Care for Complex Patients in the Patient-Centered Medical Home

‘Falling through gaps’: primary care patients’ accounts of breakdowns in experienced continuity of care

“…Ensuring that vulnerable patients have access to a primary care provider who can act to navigate their access through their care may need to be addressed through wider changes to policies and systems for working with vulnerable patients in primary care. 33 Alongside this, GPs need support and training in managing and supporting patients who may be difficult to work with. 34,35 This will help ensure that vulnerable patients do not become detached from health care, but also reduce the overuse of emergency services such as GP out of hours services and A&E that can happen when patients do not know where else to turn.…”

Measuring Comprehensiveness of Primary Care: Challenges and Opportunities

“…1,20 The U.S. decline may be due to numerous factors, including the dramatic growth in the number of specialists, health plans that enable direct access to specialty care for common conditions, specialist-oriented medical centers, and insufficient support of and payment for practices to comprehensively manage the expanding population of patients with comorbidities. 1,[21][22][23][24][25][26][27][28][29][30][31][32] In addition, patient-centered medical home (PCMH) 33,34 standards include other primary care features, such as accessibility and coordination, 35-38 but underemphasize comprehensiveness. 39,40 Some include a one-time health risk assessment and reminders about individual services for Bindividual conditions.^Although some PCMH recognition tools include care management plans that begin to address the notion of comprehensiveness, they seldom highlight the scope of services offered and the extent to which conditions and comorbidities are managed by the primary care practice.…”

Disentangling the Linkage of Primary Care Features to Patient Outcomes: A Review of Current Literature, Data Sources, and Measurement Needs

“…[89][90][91][92] Patients also have differing constellations of acute and chronic conditions, functional limitations, expectations, and family and community resources-all of which affect the amount of care coordination required and the complexity of delivering comprehensive care to them by the practice team. 93 Nonetheless, while patients may prioritize different elements of primary care at different times in their lives, they will likely benefit from all five elements for much of their lifespan. 4,5,17 And while young working-age (e.g., 40-60 years) persons may place different levels of emphasis on continuity with a primary care clinician, it is precisely this age group that benefits from early identification and secondary prevention for common asymptomatic conditions such as hypertension, hyperlipidemia and type II diabetes by a clinician who knows them well, 4 potentially avoiding future morbidity and higher costs (compared to patients for whom these conditions go undetected and unmanaged).…”

“…The goals of primary care teamwork include offloading nonclinical tasks from physicians, making more efficient use of all available professionals, and enhancing the comprehensiveness and coordination of care. 22,93 The primary care team may serve homebound patients and collaborate through "virtual" practice locations. 94 Ownership arrangements are also more complex, ranging from more traditional physician-owned practices, which may or may not be part of provider networks, to practices fully owned by health or hospital systems.…”

“…Patient-centered medical home (PCMH) initiatives, 107,108 which strive to bolster primary care through increased reimbursement and the creation of guideposts for practice capabilities, 109 include varying support for these tools. 93,110,111 The conceptual framework also notes the potential role of health plans and payer policies. PCMH initiatives ,107,108,112 for example, may lead to a better understanding of the measurement, support and use of alternative payment models for primary care.…”