The American Public Health Association (APHA) has 3 overarching policy priorities: rebuilding the public health infrastructure, ensuring access to care, and reducing health disparities.1 The health care home model, as we will describe in detail, contributes to these goals by improving health care delivery at the patient level through redesign and expansion of the scope of primary health care services and by improving the interface between primary care practices and public health agencies.
Improving access and reducing disparities are hallmarks of the APHA policy statements on topics including adolescent health,2 asthma,3 cardiovascular disease,4 diabetes,5 disabilities,6 immunization,7 infectious disease,8 birth outcomes,9 obesity,10,11 oral health,12 and vision care.13 In this policy statement, we describe the health care home model. This is the terminology used by the National Association of Community Health Centers (NACHC) to describe a model that is also referred to as the “medical home.”14,15 The health care home model is a vehicle by which patient- and family-level care at the point of delivery may contribute to meeting population-level goals of improving access to care, reducing health disparities, increasing preventive service delivery, and improving the management of chronic diseases. Throughout this document, we will use the term health care home as a more appropriate reflection of the public health implementation of the model, including its use in safety net health facilities such as community health centers.16
Elements of the Health Care Home Model of Care
The medical home concept was introduced by the American Academy of Pediatrics in 1967 as a model of care for children with special health care needs. It was intended to help coordinate multidisciplinary care from diverse sources to treat children with complex medical conditions and developmental problems and incorporate primary care as well to treat the whole child, not just the disease. The model emphasizes care that is
As the model has evolved, additional elements were added. The model has often been referred to as the patient-centered medical home after the concept of patient centeredness was identified as an important domain of quality care by the Institute of Medicine in 2001.19 The patient-centered medical home was described in 2007 through a Statement of Joint Principles by the American College of Physicians, American Academy of Pediatrics, American Academy of Family Physicians and American Osteopathic Association and subsequently endorsed by the American Academy of Nurse Practioners20 and American Dietetic Association.21 It includes the following:
The enhanced medical home model has been introduced as a model of care for medically underserved, high-risk populations. Alternative modes of primary care service delivery are emphasized, for example, school-based health centers25 and mobile medical clinics.26 School-based health centers have demonstrated clinical efficacy, including reduction of child health disparities27 and clinical outcomes for mental health care comparable to those in community clinics.28 Mobile clinics are associated with significant health system savings by preventing hospital and emergency department use.29 This enhanced model of care also includes the following elements:
Use of the term health care home helps avoid some of the problems associated with the term medical home. Several professional groups who advocate for the medical home describe it as being physician directed, which has been taken as both moving the focus of the model from patients to physicians and limiting the range of primary care providers who can implement the model to board certified physicians as was done in the federal (Center for Medicaid and Medicare Services) medical home demonstration project.31 The health care home model may be implemented by the full range of primary care providers, including diversely specialized physicians (e.g., pediatricians, internists, obstetrics/gynecology specialists, family practitioners, gerontologists), nurse practitioners and advanced practice nurses, physician assistants, osteopaths, and others approved within their state. The interdisciplinary team integral to the model includes diversely credentialed health professionals who provide mental health and substance abuse treatment; oral health; nutrition; orthopedic care; hearing and vision care; chiropractic health; podiatry; physical, occupational, and speech therapy; health education; social work; case management; public health nursing; home visiting; interpretation and translation; patient navigation; and other services as needed to comprehensively and holistically treat the patient. Depending on the patient’s needs, the model may be implemented by a mental health professional or other specialist.32
The Role of the Health Care Home Model Within Public Health
Goals of the Health Care Home Model
The health care home model attempts to reduce barriers to access by providing enabling services such as facilitated enrollment in health insurance, transportation, extended visit hours, and integration of key specialty services at the primary care site, which serves as the locus of care coordination. Co-location of multiple services at the primary care site facilitates same-day appointments with different providers.33
The health care home model provides a continuous source of medical consultation, referrals, and prescriptions that can reduce health care costs by providing an alternative to emergency department visits and early medical intervention that prevents hospitalizations. Conversely, not having access to primary care in a health care home model contributes to racial and ethnic health disparities34 and higher emergency department use.35
To improve clinical outcomes, the model also emphasizes the role of health information technology. Electronic health records promote the use of guidelines-based best practice protocols to improve chronic disease management36; facilitate care coordination and flow of information among multiple providers caring for a patient with complex health care needs37; and increase the patient-centered quality of care by encouraging nontraditional visits (telephone and e-mail)38 and improved patient self-management and adherence to medication (text, e-mail, and Web reminders). The model has a strong emphasis on wellness, and electronic health records help increase receipt of preventive care.39 These are critically important elements of care for the medically underserved.
Integration of mental health and primary care services is an essential element of this model. The responsibility to treat psychiatric disorders has increasingly shifted to primary care providers, in part because of mental health provider shortages.40 Among adolescents, most psychotropic medications for mood disorders are prescribed and managed in medical rather than mental health treatment settings.41 Among adults, most people with depression do not receive treatment, and most of those who are treated do not receive care consistent with best practice guidelines. African Americans and Latinos are especially likely to go without treatment.42
Mental health treatment is often an essential component of effective chronic disease management. Patients with anxiety disorders use more primary care and medical specialty services than other patients, incurring greater health care costs.43 Among patients with cardiovascular disease, depression is associated with patient and provider perception of greater symptom severity and worse quality of life.44 Major depression is associated with increased mortality.45 Among patients with diabetes, those with psychiatric disorders are less likely to receive screening that may prevent serious diabetic complications such as foot, retinal, and renal examinations.46
Although the model originated in pediatrics, the health care home model is not population specific. It is culturally and linguistically appropriate and can be tailored to the needs of the local community and of specific patient populations.
Comprehensive and coordinated care are key elements of the health care home model and integral to centers of excellence that have been developed to improve women’s health care services.47
As the general population ages, the health care home model is uniquely positioned to meet new demands, such as transportation assistance, chronic disease management, increased coordination of care providers and long-term provider continuity, and health information technology integration at the point of health service delivery. The Institute of Medicine has shown these health care system reforms, all features of the health care home model, to be essential in meeting the needs of an aging US population. The Institute of Medicine anticipates that there will be nearly twice as many older adults in 2030 as there were in 2005.48
Efficacy of the Health Care Home Model in Reducing Health Disparities
Consistent in all of these elements and the goals of the health care home model is the reduction of racial, ethnic, and socioeconomic health disparities. The Agency for Healthcare Research and Quality, in its 2009 report on health disparities, found that minority and poor people;
These health disparities have not substantially improved over time.49
The New York State Primary Care Coalition found that the health care home model is a cost-effective way to
All of these outcomes contribute to the reduction of health disparities.50
The health care home model is significantly associated with receipt of more preventive health care services and with fewer hospitalizations.51 In 2006, the Commonwealth Fund’s Health Care Quality Survey found that having access to a health care home improved timely receipt of preventive screening and reduced disparities in receipt of cholesterol, breast cancer, and prostate cancer screening.52 Receiving this enhanced quality of primary care is associated with higher rates of being up to date for immunization for children in poverty and other at-risk children.53,54
The health care home model contributes to the reduction of disparities in the incidence, severity, and morbidity of ambulatory sensitive55 and chronic conditions that disproportionately affect poor and minority adults, such as diabetes,56 cardiovascular disease,57 and HIV.58 Studies of effective programs for diabetes management show a reduction in hospital use and associated costs through implementing components of the model including culturally and linguistically relevant patient health education59 and a team approach including a clinical nutritionist.60
Reports by former US Surgeon General Satcher and by the Institute of Medicine have found that integration of mental health services in the primary care setting is associated with improved patient access and better clinical outcomes.61,62 This model may be especially valuable in improving access to treatment for low-income and minority people with substance abuse disorders.63 There is evidence of efficacy for primary care management of substance use disorders, a model of care integral to the health care home.64,65
Several studies report that women often put their own health care needs last. Women who receive care in a health care home model are more likely to take advantage of co-located services and coordinated systems and to seek care for themselves when bringing a child or partner to a medical appointment. For example, an innovative program for grandparents (mostly grandmothers) caring for their children’s children found that co-locating women’s health services with pediatrics in a family practice health care home model engaged older women in health care once the grandchild’s health needs had been met. For many of these women, care was resumed for serious chronic conditions including diabetes and cardiovascular disease.66 Key elements of the health care home model—coordination and comprehensiveness of care, use of clinical practice guidelines and health information technology, and a patient- and family-centered focus—contribute to improvements in delivery of preventive health screening for women and potentially narrow the gender gap in this area.67,68
Care coordination for patients with chronic illness is associated with reduced emergency department use.69 The efficacy of the health care home model in reducing hospitalizations and emergency department use has been powerfully demonstrated in outcome studies of children with asthma.70 In North Carolina, hospitalizations and emergency department use, which are indicators of inadequate asthma management in primary care and hallmarks of asthma disparities, were substantially reduced with significant reductions in Medicaid expenditures.71 Savings of more than $4,000 per pediatric asthma patient per year were found in an outcome study of a program that implemented evidence-based asthma care in a health care home model in New York City.72
A key element of the health care home model, use of health information technology, has been independently found to have significant benefits in improving health care delivery, reducing costs, and reducing disparities. Health information technology includes the following elements:
It has been suggested that enhanced primary care reimbursement to sustain care coordination could also support further development and implementation of electronic health records.76
Limitations of the Health Care Home Model
The health care home model is an effort to expand the scope of primary care delivery and to change the paradigm from illness and treatment to wellness and prevention. Its principle limitation is its reliance on primary care providers and settings to accomplish a broad range of activities, including care coordination and facilitated access to community and medical specialty services that may be needed. This limitation may lead to other significant problems, such as the cost of care relative to reimbursement rates and the degree to which the primary care service is integrated into the broader community setting. Some have suggested that the medical home model excludes other health care disciplines from participation, which is one reason why the term health home is preferred by many in the public health community.79
Cost of Care
Providing extended visits, incorporating care management and coordination, providing more preventive screening, and attending to patients’ psychosocial needs leads to longer visits and less third party revenue. Longer visits must be compensated by increasing the per-visit primary care reimbursement rate.8
Reimbursement for non–face-to-face patient contacts is essential to the successful implementation of the model,81 as is reimbursement for multidisciplinary team meetings to facilitate coordinated care.82 Low reimbursement rates for mental health and substance abuse services have been linked to provider shortages and difficulty accessing care. Payment issues include restrictions on reimbursement for collateral contacts, which are essential to mental health care. Including mental health care in the scope of practice of the primary care provider is hindered by limitations on reimbursement for management of psychiatric disorders in the primary care setting.83
A methodology is in place to have primary care practices certified as medical homes and a certification agency, the National Committee on Quality Assurance (NCQA) has been selected to evaluate practices and confer certification.84,85 The model that NCQA has used to develop a 3-tier certification (depending on the elements of the model implemented) process is that of the patient-centered medical home, which has often been described as a physician-driven model and therefore interpreted as not fully including the range of primary care providers who deliver care. Assuming medical home certification is obtained, whether the practice will be reimbursed at a higher rate, and what that rate would be (for each level of certification), is at the discretion of each state for public insurance and at the discretion of each insurance organization for commercial insurance.
The enhanced reimbursement that the NCQA certification potentially allows is restricted to the primary care practice. Significant reimbursement issues affect many other health disciplines essential to achieving the goals of the health care home. For example, although there has been a recent emphasis on the health problems and costs associated with pediatric overweight and obesity, nutrition services are not generally reimbursed in the absence of a diagnosis such as diabetes or hypertension, despite the demonstrated efficacy of counseling by a registered dietician in treating childhood obesity.86 The primary care focus of the health care home model may not adequately address reimbursement issues in other health care disciplines.
Limited Community Focus
An alternative model also was developed in the 1960s: community-oriented primary care (COPC). The COPC model is associated with the inception of the community health center model and is a combination of public health methodology and primary care practice. It was recommended in 1982 by the Institute of Medicine as an essential element to improving primary care. Pilot projects done at that time demonstrated that the model had value in improving care for medically underserved patients but showed that it could not be sustained without adequate funding. The COPC model was adopted as part of residency training for family practitioners in 1999.87
Key elements of the COPC model include the following:
The COPC model goes beyond the primary care setting by attempting to address social determinants of health within a geographically defined area. It is a community health– and population-based model; by contrast, the health care home model focuses on the individual patient and family. Both models emphasize wellness and prevention, but the COPC model goes further in engaging the larger community and its resources (e.g., housing, parks and other public spaces), and the quality of the environment. In this regard, the COPC model is more consistent than the health care home model with public health approaches to population wellness, and the successfully implemented COPC model could be more effective in reducing health disparities that disproportionately affect vulnerable populations. However, the COPC model has not been widely implemented in practice. Reimbursement problems persist and make it difficult for COPC practices to sustain the necessary level of effort.89,90 There is no process currently in place for such reimbursement enhancement for COPC practices similar to the NCQA certification process that may support the health care home model.
An extensive literature review done in 2008 found insufficient evidence of efficacy for the COPC model. Many of the studies referenced implemented only parts of the model, and evaluations of community outcomes and community participation were not completed. Further research is needed to appropriately test the model; to date, COPC is better accepted as a training modality, especially in family practice, than it is as a model for health care delivery.91
The 2 models, however, are not mutually exclusive. COPC could exist within the context of a health care home model and vice versa. The COPC model adds the benefit of community health planning, community-level health interventions, and sociomedically and epidemiologically based research and environmental interventions, which can further enhance the primary care of both people and communities.
Primary Care Provider Shortages
An estimated 65 million Americans live in areas without an adequate supply of primary care providers to ensure timely access to health care when needed. The percentage of the health care workforce that practices as primary care providers rather than specialists in the United States is lower than in most other countries.92 These shortages present challenges for the practice of primary care and public health generally. They also may limit implementation of the health care home model.
The degree to which the nation’s supply of primary health care providers is critically inadequate was summarized in May 2010 by National Center for Policy Analysis.93 Fewer than half of practicing physicians are primary care providers, and, before the insurance coverage expansions of the health reform legislation of 2010, the American College of Physicians estimated that 45,000 primary care physicians were required to meet anticipated needs in 2020. After implementation of the health reform legislation, that shortage may become even greater. Increased use of nurse practitioners, advanced practice nurses, and physician assistants as primary care providers may help alleviate this shortage.93
The American Association of Colleges of Nursing, however, points out that despite increasing the size of the nursing workforce and growth in the health care sector greater than in other segments of the US economy, there continues to be a critical shortage of nurses, including newly trained nurses to replace retirees in an aging workforce. This situation is likely to contribute to a continuing shortage of primary care providers.94
NACHC reported a current shortage of 1,843 primary care providers (physicians, nurse practitioners, physician assistants, and certified nurse midwives) and an additional shortage of 1,384 nurses to meet current need. To meet the projected need by 2015, federally qualified health centers require a minimum of 15,585 primary care providers, more than one third of whom would be nonphysicians.95 Some of these provider shortages may be addressed through Title VII of the US Public Health Service Act (1963), a basis for federal assistance in medical and oral health training. Since 1992, it has focused on improving care for vulnerable populations, including the homeless, and on increasing diversity in the health care workforce.96 Residents who receive federal Title VII–funded primary care education are better prepared to provide culturally competent care because of cross-cultural training experiences.97
Health Reform Legislation of 2010 and Demonstration Projects
Health reform legislation, formally known as The Patient Protection and Affordable Care Act (PPACA) HR 3590 of 2010,98 emphasized health insurance reform. This reform is expected to help improve access to care and health outcomes and to reduce disparities. Previous expansions of public health insurance coverage have been associated with increased participation in a health care home, with all of the benefits associated with receipt of that quality of care.99 In addition, PPACA has many provisions that are directly relevant to promoting the health care home model. In this law, the term medical home is used frequently but not exclusively. The term health home is also used in the PPACA, for example, as a model of care for patients with chronic health conditions.
Although some of the language used in PPACA appears to limit primary care delivery to physicians, it defines primary care practitioner more broadly to include nurse practitioners, clinical nurse specialists, and physician assistants, in addition to physicians with “a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine.”
The PPACA defines the medical home as a model of care that includes personal physicians; whole-person orientation; coordinated and integrated care; safe and high-quality care through evidence informed medicine, appropriate use of health information technology; and continuous quality improvements, expanded access to care, and payment “that recognizes added value of additional components of a patient-centered medical home.“ It is also described, consistent with a public health orientation, as providing high-quality, effective, efficient, and safe primary care, guidance to patients in culturally and linguistically appropriate ways, and linking practices to diverse health system resources [to] improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives.
Pilot projects will be implemented by “contracting directly with groups of providers.“ These are intended to promote broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable people, medical homes that address women’s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment.
The model will be incentivized through “financial policies that promote systematic coordination of care by primary care physicians across the full spectrum of specialties and sites of care . . . [by] capitation arrangements, or pay-for- performance programs.“
An entire section (§3502) is devoted to processes for “establishing community health teams to support the patient-centered medical home.“ It calls for government to “provide grants to or enter into contracts with eligible entities to establish community-based interdisciplinary, interprofessional teams (referred to in this section as health teams) to support primary care practices, including obstetrics and gynecology practices, within the hospital service areas served by the eligible entities.“
The PPACA also calls for changes in medical education to provide training and continuing education to primary care physicians relevant to implementing the health care home model and providing “training in environmental health, infectious disease control, disease prevention and health promotion, epidemiological studies and injury control.“
National Pilot/Demonstration Projects
The pilot programs that will occur under PPACA may help promote the health care home model. The following are some demonstration models that have begun:
Preliminary Evaluations of Pilot/Demonstration Projects
An evaluation model for health care home demonstration projects has been proposed, emphasizing adherence to the Institute of Medicine’s recommendations for restructuring the primary care system. Practices would be assessed to determine whether they are safe, effective, patient centered, timely, efficient, and equitable.104
In a survey of 26 demonstration projects in 18 states that were active in 2009, investigators questioned whether reimbursement systems adequately supported the model, and noted that demonstration projects were not being adequately evaluated.105
A Medical Home Index has been developed to assess the degree to which primary care practices are consistent with the model, with ratings derived from a 100-point scale in 6 practice domains: organization, chronic care management, care coordination, community outreach, data management, and continuous quality improvement activities.106 Using this index, investigators assessed whether 43 pediatric primary care practices implemented by 7 health insurance plans in 5 stat
