Understanding Medical HomesA European study funded by the Commonwealth Fund

Marjan J FaberGE VoermanBaker R, Constantinidis A,De Lepeleire J, Eriksson T, Lilienkamp CRichard PTM Grol

Introduction (I)• Concept introduced in the US 40 years ago, in order to face the care for children

with special health care needs [CSHCN] (Sia et al., 2004)

• Medical Home is defined as A place—a single source of all medical information about a patient

A partnership approach with families to provide primary health care that is

1) accessible 2) family centered

3) coordinated 4) comprehensive

5) continuous 6) compassionate

7) culturally effective(Sia et al., 2004)

Medical Home: domains

1. A personal physician (3)

2. Physician-directed medical practice (3)

3. Whole-person orientation (8)

4. Coordination/integrated care (5)

5. Quality and safety (8)

6. Improved access (6)

7. Payment (3)Source: Joint Principles of the Patient-Centered Medical Homes (2007)

Problem definition

– There is no research evidence on the characteristics of the MH in European primary care

– There is no evidence on whether care provided according to the MH is associated with patient population, practice, or healthcare system characteristics

– There is no evidence on best practice

Project goals

• To achieve consensus about the concept of MH• To describe and compare current (and desired) care provision according to the MH

concept in a number of (European) countries with strong primary care systems• To analyze the degree of care provided according to the MH concept in relation to

characteristics of patients, practices, and countries• To identify best practice for MH and the problems that are encountered in

organizing a MH

Part 1 of MH project: Literature review and expert consultation Part 2 of MH project: Instrument development Part 3 of MH project: Fieldwork Part 4 of MH project: Analysis, interpretation, and dissemination

Part 1

Literature review & expert consultation

Part 2

Instrument development

Instrument development

Requirements instruments: Short and simple to complete

Addressing corresponding elements between the 3 instruments when possible

Target # items Details

Patient 38 5 about patients’ health6 about socio-demographics27 about MH care

Professional 33 6 about socio-demographics27 about MH care

Practice 26

Part 3

Fieldwork

Fieldwork: 5 countries

Source: Starfield & Shi, Health Policy 2002

Low performing countries

High performing

countries

# included** BE* DK GER UK NETH

Practices & GPs n=151 21 35 36 34 26

Patients n= 5598

- Total

- with chronic condition

- with chronic condition & at least

one practice visit in last year

764

695

677

1132

905

890

1848

1848

1805

1210

976

965

1474

1302

1273

Overview of data collection

* Flemish practices only** Overall responsratio 35%

Practice characteristics

Practice characteristics

Practice BE DK GER UK NETH

Number of employees in practice (fte, mean) GPs other healthcare providers other employees

3.71.11.1

2.42.41.2

1.52.80.6

4.44.712.7

1.32.3--

Number of patients seen per week in practice 201 175 329 477 200

Number of home visits (relative to number of practice visits

0.35 0.01 0.07 0.04 0.05

Number of telephone consultations (relative to the number of practice visits)

0.94 0.75 0.33 0.13 0.44

IT performance

Practice BE DK GER UK NETH

Does your practice use a computerized medical record system? (% yes) 100 100 83 100 100

Do you use your computer to send electronic prescriptions directly to pharmacies? (% yes) 5 100 0 15 96

Does your medical record system allow ….. you to share your patients’ medical records

electronically with clinicians outside your practice (% yes)

.. you to access your patients’ medical records when you are outside the office? (% yes)

.. your patients to directly access their own medical records? (% yes)

35

45

0

6

71

91

22

36

0

47

3

3

63

59

0

Tracking

Practice BE DK GER UK NETH

Does your practice have a list of enrolled patients? (% yes) 95 97 17 94 85

Does your practice have a systematic approach for … … managing information regarding outgoing

requests? (% yes) … archiving incoming patient information in the

medical record? (% yes)… tracking patient test results that come in, to ensure

that the clinical and patient have been notified of test results? (% yes)

… reminding patients about preventive care that is due? (% yes)

30

90

65

15

6

3

14

43

42

89

61

44

91

97

88

100

67

100

100

44

Quality and safety

Practice BE DK GE UK NETH

Do GPs have access in the practice to guidelines? (% yes) PR_12

80 100 86 100 89

Do GPs have access in their practice to medical literature? (% yes) PR_13

85 83 58 79 83

Has the practice undertaken at least one clinical audit in the last 12 months? (% yes) PR_14

20 82 83 97 41

Does the practice produce an annual report? (% yes) PR_15

10 14 25 53 71

Does the practice have a patient complaint procedure? (% yes) PR_19

15 31 53 100 92

Improved access

Practice BE DK GER UK NETH

Separate phone number for emergency calls (% yes) 40 66 28 27 100

Booking interval for routine appointments (mean (sd))

16 (4) 14 (2) 13 (3) 10 (0) 10 (3)

Proportion of same-day appointment: >75% 95 46 61 85 36

Office hours (% yes) < 8 am > 18 pm weekend

309535

50926

318611

245929

000

Patient experiences

Patient characteristics (1)

Patients BE DK GER UK NETH

Age (mean (sd); yr) 68 (13) 66 (11) 64 (13) 65 (13) 64 (12)

Gender (% male) 47 49 43 46 44

Education (%)High school or lessSome collegeCollege degree or higher

513116

622117

74179

503516

513316

Income (%)Much above averageSomewhat above averageAverageSomewhat below averageMuch below average

621222031

1029311813

519152636

411193035

1122271724

Born in country (% yes) 94 98 90 94 94

Patient characteristics (2)

Patients BE DK GER UK NETH

Health status (%)Excellent / Very goodGoodFair / Poor

84745

263341

43066

183845

64054

Chronic condition (% yes) Asthma / COPD Diabetes mellitus Hypertension Cardiovascular diseases Anxiety Depression Cancer Arthritis

122246266102323

1429542347623

183059295131136

25334622710930

2137532047523

Number of conditions (% > 1) 48 42 59 50 48

Number of practice visits (% ≥ 5) 67 44 65 51 48

Personal physician

BE DK GE UK NETH

When you had a medical problem, did you usually consult the same GP? (% yes) PA_B1

98 87 94 74 89

Recourse & team management

Patients BE DK GE UK NETH

How often did you feel confident that your GP’s staff worked well as a team to provide care for you? PA_B9

% always% often% rarely/never

70228

77221

74233

66295

553313

Were responsibilities and divisions of tasks of the members within the general practice team clear? (% yes) PA_B10 98 97 96 94 94

Whole person orientation (1)How often did your GP …. BE DK GE UK NETH

…. show interest in your psychological wellbeing? PA_B5

% always% often% rarely/never

462516

423424

443521

453124

382438

…. show concern about you and your home circumstances? PA_B8

% always% often% rarely/never

592517

463123

343829

413029

372835

…. listen carefully to you? PA_B6% always% often

8016

7323

7521

7521

6933

…. explain things in a way you could understand? PA_B7

% always% often

8313

7423

7322

7423

7220

Whole person orientation (2)How often did your GP ….. BE DK GE UK NETH

…. involve you in decisions regarding your treatment plans? PA_B16

% always% often% rarely/never

79165

76195

65269

67239

662212

…. verify whether your expectations were met at the end of the consultation? PA_B17

% always% often% rarely% never

602686

623053

30271825

49301210

42291812

Whole-person orientation (3)How often did your GP … BE DK GE UK NETH

… encourage you to manage aspect of your condition yourself , by giving you a written plan or instructions to help you manage your own care at home? PA_B20

% always% often% rarely% never

5925115

28361224

32321422

29341225

27322120

…. give you easy to understand advice on how to prevent diseases and how to improve your health? PA_B21

% always% often% rarely/never

572915

433917

414217

424018

353134

Coordination of care (1)

BE DK GE UK NETH

Has your GP organized and coordinated care provided by others for you (e.g. hospital care, prevention)? (% yes) PA_B2

87 76 85 81 82

Has your GP communicated with community care about your health problems or care needs when necessary? (% yes) PA_B3

60 13 21 37 49

Coordination of care (2)

Patients BE DK GE UK NETH

How often was your GP well informed about out-of-hours care provided to you by other doctors? PA_B14

% always% often% rarely% never

79164<1

6010327

6813910

532999

5828122

Was your GP well informed about the care you received by other health care providers and services? (% yes) PA_B4

98 89 94 89 93

How often was your GP well informed about laboratory results, radiology reports, and specialist consultations? PA_B15

% always% often% rarely

9082

86112

76194

76222

74195

Quality & Safety

Patient BE DK GE UK NETH

If you have had a complaint about your GP or practice, did you feel satisfied with the procedure? (% yes) PA_B19

90 49 78 66 83

How would you rate the quality you receive in your GP practice? % excellent% very good% good% fair / poor

3845152

3941174

2541304

4437154

2235348

Improved AccessPatients BE DK GE UK NETH

Did you have access to your medical records? (% yes) PA_B11

75 57 27 44 58

How often did your GP or the staff member responsible for the appointment schedule, do the best to give you an appointment that fitted your expectations? (% always) PA_B13

83 81 73 58 66

Was it possible for you to contact your GP by email? (% yes) PA_B22

55 80 30 38 53

In general, was it easy for you to contact your practice by phone during office hours? (% yes) PA_B23

98 97 93 90 82

When you phoned the practice out of hours, were you given information about how to get care out of hours? (% yes) PA_B24

58 96 93 97 96

Did your GP practice have a website with information on, for instance, office hours and telephone numbers? (% yes) PA_B25

92 96 52 87 88

PaymentPatients BE DK GE UK NETH

In the past 2 years, did you have problems in visiting your GP because of costs? (% yes) PA_B26 5 1 5 2 1In the past 2 years, could you get primary care without spending any out-of-pocket costs for medical treatments or services? (% yes) PA_B27 24 87 79 90 84

GP’s experiences

Lessons learned

Domain Best practice Diver for best practice

(Practice organization) UK QoF

Personal physician All

Medical team Denmark, Germany Disease management programs

Whole person orientation Belgium

Coordination Belgium

Quality & Safety Belgium

Improved access Denmark

Payment Denmark, UK

As to Flanders (Belgium)

• Very satisfied patients

with high level

- home visits

- same day appointments (95%)

- Regular visits after 6 pm

- consultation in the weekend

- patient expectations are met

As to Flanders (Belgium)

but:

•Low level of– Clinical audit– Annual reports– Compliant procedure– Concertation with other professionals– Attachmen t guidelines– Preventive actions– Direct patient access to medical file

– High cost for patients

Special thanks to ...

• Richard Baker, Leichester, United Kingdom• Jan De Lepeleire, Leuven, Belgium• Antje Erler, Frankfurt, Germany• Tina Eriksson, Copenhagen, Denmark• Gerlienke Voerman, Jako Burgers & Richard Grol, Nijmegen,

the Netherlands

• Robin Osborn, Commonwealth Fund, New York, US

Additional analysis

• Non-response analysis

• Relation between patient experiences and characteristics of:– Patients– GP practices– Healthcare systems

• Relation between patient ratings and professional ratings for same item

• Include interviews with best practice GPs

AUS(n=1009)

CAN(n=3003)

GER(n=1407)

NETH(n=1557)

NZ(n=1000)

UK(n=1434)

US(n=2500)

The adult has a regular doctor or place of care (% yes) 96% 91% 94% 100% 95% 97% 90%

Doctor(s)/staff know important information about the patient’s medical history (% always or often)

85% 84% 93% 90% 87% 79% 82%

The place is easy to contact by phone during regular office hours (% yes)

86% 78% 66% 75% 88% 80% 81%

The doctor(s)/staff at the source of care help coordinate care received from other doctors or sources of care (% always or often)

70% 67% 67% 55% 70% 58% 69%

The adult has a medical home (% yes)

59% 48% 45% 47% 61% 47% 50%

Scoring across 7 countries on key-elementsfor a medical home (Schoen et al 2007)

AUS = Australia; CAN = Canada; GER = Germany; NETH = Netherlands; NZ = New-Zealand; UK = United Kingdom; US = United States.