First Principles: PCMH for Patients with Chronic Illness

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These days I am frequently asked whether the PCMH model “works.”  My usual response is that the PCMH model works well for patients with chronic illness because they are the folks who most need what the PCMH model offers.  The PCMH model can also work well for patients who are at high risk for chronic conditions, such as those who are pre-diabetic or pre-hypertensive.  Healthy patient populations with minimal risks do not necessarily need the full-blown PCMH model, but if they ever do need chronic illness care they will be glad they are enrolled in a PCMH practice.

Community Health Solutions has advocated for the Chronic Care Model and the PCMH model in safety net settings for the simple reason that safety net providers serve large numbers of chronically ill patients.  The typical free or charitable clinic, federally qualified health center, rural health clinic, or community services board serves a population in which half to three quarters of the patients have one or more chronic conditions.   Going back to the Institute of Medicine Crossing the Quality Chasm Report and long before that, there is overwhelming evidence that fragmented, uncoordinated systems of care are not good for chronically ill patients.   The PCMH model is designed to improve chronic care as well as preventive and primary care services for all patients in the practice.

When the PCMH model is effectively implemented, it becomes the Chronic Care Model for patients with chronic illness, and this should help patients do better.  As always, actual patient outcomes will depend on how well the PCMH model is actually implemented, and whether patients take full advantage of what is offered.  And, it is worth noting that some practices have made a thoughtful decision not to seek external recognition as a PCMH.  But this does not necessarily mean that the design of the PCMH model is unsound.

As an exercise to check my own thinking on the PCMH model design, every now and then I review the PCMH standards and ask myself: Which of these capabilities would I want my primary care practice to have in place, especially if I had a chronic illness?    I also invite other people to do the same. In case you might like to give this a try, below is the NCQA PCMH framework of standards, elements, and factors.  I invite you to browse through this framework from the perspective of a person with one or more chronic conditions.  As you do so, ask yourself: How much would I as a patient value each capability listed in the framework?  I will be very interested in your findings, whether they are positive, negative, or neutral.  (Note: Click the down arrows to view the specific factors that go with each element.)

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