THE MEDICAL HOME:

Improving Its Fit with the Frail Elderly and Other Special Needs Populations
By: Dennis Kodner* October 2011

SUMMARY While the medical home is considered a mainstream avenue to improve the delivery and financing of primary care, perhaps its greatest potential is as a comprehensive primary care approach for special needs populations with chronic, multimorbid, disabling and medically complex conditions. However, this would require much further elaboration of the model as it is known. This paper was commissioned to ask the question: What needs to be done to make the medical home a more accommodating environment to provide comprehensive primary care services to special needs patients? To better address the complex needs of these high-risk, high-cost patients, our analysis strongly suggests that the medical home model incorporate targeted, evidence-based approaches known to work with the various populations, as well as more specialized aspects of successful population-specific programs. Some of these key interventions and components are sketched in the paper. This is the third in a series of papers that critically examine key policy and service delivery issues and options related to various special populations. The first paper looked at New York States People First Waiver for people with developmental disabilities from the perspective of Medicaid managed care.1 The second paper in the series focused on the dual eligible dilemma and the strategic implications for integrated models of care which bring together Medicare and Medicaid.2 INTRODUCTION AND BACKGROUND This paper looks at the medical home model, including its evolution and implementation, and ultimately its fit with special needs of the frail elderly and other groups with chronic, disabling and medically complex conditions. The medical homea promising concept first introduced in the late-1960s to enhance the coordination of pediatric services for medically fragile children3has now taken center stage in efforts to reform primary care, as well as the overall healthcare system. Advocates believe that the widespread availability of medical home-like approaches could enhance improve access to needed services, increase patient satisfaction with care, improve cost-effectiveness, and lead to better health outcomes.4 Also known as the patient-centered medical home and advanced medical home, the medical home is an innovation designed to address a wide range of deficiencies in the exiting primary care system: overemphasis 1 Kodner, D., New York States People First Waiver: Concept Paper on Strategic Issues and Options Related to the Development of Innovative Medicaid Managed Care Models for Developmentally Disabled Adults, Arthur Webb Group, Inc., n.d. 2 Kodner, D., Dual Eligibles: Understanding this Special Needs Population and Options to Improve Quality and Cost-Effectiveness of Care Through Integrated Solutions, Arthur Webb Group, Inc., September 2010. 3 Sia, C. et al, History of the Medical Home Concept, Pediatrics 2004; 113 (5 Suppl): 1473-8. 4 See J. Martin et al., The Future of Family Medicine: A Collaborative Project of the Family Medicine Community, Annals of Family Medicine, 2 (Suppl 1): S3-32; also Starfield, B. and Shi, L., The Medical Home, Access to Care, and insurance: A Review of Evidence, Pediatrics, 113 (5 Suppl): 1493-8.

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on specialization and specialty referrals, dangerous shortage of primary care physicians, population aging and increasing burden of chronic disease, focus on episodic care, coordination and continuity of care problems, and archaic fee for service (FFS) payment methods that do not promote quality or efficiency.5 The concepts of medical neighborhood and health neighborhood6, but especially the new health home model, is designed to align services and care outside the medical home with the physician-led, comprehensive primary care services of the medical home. 7 There is enormous interest in medical homes in both the public and private sectors, with well over 100 medical home initiatives nationally aimed at both enhancing primary care, as well as better management of chronic illness.8 The Affordable Care Act (ACA) authorizes the testing of broad payment and practice reforms for primary care, including the medical home model.9 DEFINITIONS AND COMPONENTS OF THE MEDICAL HOME The medical home is not so much a place, as a more a patient-centric, holistic philosophy and approach to primary care in which the personal physician, backed by a care team, works with the patient and patients family to provide comprehensive, continuous, coordinated services.10 The approach is flexible enough to be developed within a variety of settings: individual or group medical practice, primary care clinic, health center, managed care plan, integrated delivery system, accountable care organization (ACO), etc.11 There are a number of overlapping definitions of the medical home. The most well-known definition is found in the March 2007 joint statement of the primary care societiesAmerican Academy of Pediatrics (AAP), American Academy of Fam5 Kodner, D., The Medical Home: An Introduction. Presentation at Symposium on the Medical Home, NYIT Center on Gerontology & Geriatrics, New York College of Osteopathic Medicine, Old Westbury, NY, May 27, 2009. 6 The medical neighborhood and health neighborhood conceptually represent connections with the outside world that are considered essential to the success of the medical home model (and traditional primary care practices). The former refers to collaborative links with the constellation of medical specialists, hospitals and other specialized medical resources, while the latter refers to supportive relationships with the array of behavioral health care, home and community support services, long term care, and other health and human service providers. 7 The health home model of coordinated service delivery is an important adjunct to the medical home. Primarily focused on the complex needs of people with multiple chronic conditions, the health home is designed to build connections with other community-based services and supports, as well as enhance coordination between medical, behavioral, and long term care services. The health home was created as a Medicaid option in the Affordable Care Act (ACA), and became available to states starting January 1, 2011. Because the ACA authorizes a temporary 90% federal match (FMAP), a number of states, including New York, have or are in the process of amending their state Medicaid plans to implement the health home model. Covered services include comprehensive care management, care coordination, health promotion, transitional care, individual and family support, community referral services, and health information technology (HIT) to link services. For further details, see Kaiser Family Foundation, Medicaids New Health Home Option, Publication #8136, January 2011. 8 The health home model of coordinated service delivery is an important adjunct to the medical home. Primarily focused on the complex needs of people with multiple chronic conditions, the health home is designed to build connections with other community-based services and supports, as well as enhance coordination between medical, behavioral, and long term care services. The health home was created as a Medicaid option in the Affordable Care Act (ACA), and became available to states starting January 1, 2011. Because the ACA authorizes a temporary 90% federal match (FMAP), a number of states, including New York, have or are in the process of amending their state Medicaid plans to implement the health home model. Covered services include comprehensive care management, care coordination, health promotion, transitional care, individual and family support, community referral services, and health information technology (HIT) to link services. For further details, see Kaiser Family Foundation, Medicaids New Health Home Option, Publication #8136, January 2011. 9 For example, see The Robert Wood Johnson Foundation, Patient-Centered Medical Homes, Health Policy Brief, September 14, 2010. 10 American Hospital Association (AHA), Patient Centered Medical Home: AHA Research Synthesis Report, September 2010. 11 Physicians in small- to medium-size primary care practices may find it especially difficult to accept the tenets of the medical home and the wherewithal to convert to new model. The transformation demanded not only affects professional identity and traditional practice patterns, but also requires retraining and major financial investment.

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ily Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Associationin which the patient-centered medical home is defined as both an approach to providing comprehensive primary care for patients of all ages, as well as a health care setting that facilitates partnerships between individual patients, their personal physician, and the patients family, when appropriate.12 Indeed, this definition dovetails with an earlier and more expansive definition of primary care adopted by the Institute of Medicine, namely the provision of integrated, accessible health care services by clinicianswho are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in context of family and community.13 In a more concrete sense, there are eleven (11) essential or core elements in the generic medical home model:14 X Primary care physician with back-up from a physician-guided inter-professional team X Whole person orientation X Systems-based approach to quality and safety, including evidence-based practice and ongoing performance measurement and improvement X Proactive, planned visits instead of reactive, episodic care X Support for management of chronic conditions X Coordinated care across all settings X Patient-involvement in decision-making X Enhanced communication and access X Electronic medical record (EMR) and other health IT X Accountability for performance and outcomes X Appropriate payment methods and incentives to promote efficient, effective care.15 To summarize, the medical home is envisioned as the central hub for patient information and partnering, primary care delivery, and care coordination. It places high priority on patient involvement, as well as the patients needs and preferences. Ongoing care is coordinated by a physician-led team consisting of nurses, care managers, and others. Evidencebased population health measures and a focus on quality improvement are incorporated into the processes of care. And the medical home is held accountable for the provision of high-quality care. MEDICAL HOME AND THE CHRONIC CARE MODEL While the medical home is intended for all patient groups, it is particularly relevant to the needs of the frail elderly and other special need populations, including those with chronic and disabling conditions. People with complex illnesses, physical and developmental disabilities, HIV/AIDS, etc. suffer with complicated and costly health care needs that are poorly served by primary care and the rest of the healthcare system, behavioral health and long term support services included.

12 American Academy of Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, Joint Principles of the Patient-Centered Medical Home, March 2007. 13 Institute of Medicine (IOM), Primary Care: Americas Health in a New Era, Washington, DC: National Academy Press, 1996, p. 31. 14 See, for example, Agency for Healthcare Research & Quality (AHRQ), The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care. AHRQ: Washington, DC, Publication No. 11-M005-EF, December 2010; Robert Graham Center, The Patient-Centered Medical Home, 2007; American College of Physicians, The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care, 2006; and, Deloitte Center for Health Solutions, Medical Homes 2.0: the Present, the Future, Issue Brief, n.d. 15 Because of the importance of incentives, primary care payment reform is an essential component of the medical home strategy.

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As a result, the medical home is organized around the Model for Effective Chronic Illness Care developed by Ed Wagner, Thomas Bodenheimer, and collaborators at Group Health Cooperative of Puget Sound in Seattle and Health Partners in Minneapolis. The so-called Chronic Care Model (CCM), which is illustrated below, is a systems-oriented, evidencebased framework to facilitate the management of chronic illness. It rests on 30 specific interventions spanning six key areas: healthcare organization, community resources, self-management support, delivery system design, decision support, and clinical information systems. These elements, which cut across the health system and community setting, are designed to enable informed patients to engage in productive interaction with an experienced, proactive, interdisciplinary team, thus improving outcomes in chronic illness care. 16

16 There is an enormous literature on CCM. See, for example, Bodenheimer, T., Wagner, E. and Grumbach, K., Improving Primary Care for Patients with Chronic Illness: The Chronic Care Model, Part 1, Journal of the American Medical Association 2002; 288: 1775-9; and, Bodenheimer, T., Wagner, E. and Grumbach, K., Improving Primary Care for Patients with Chronic Illness: The Chronic Illness Model, Part 2, Journal of the American Medical Association 2002; 288: 1909-14.

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International evidence supports the models association with better processes and outcomes of care, higher patient satisfaction, and lower costs.17 Nonetheless, further research shows that many components of the model are not widely employed in the U.S., unless external incentives are involved, e.g., financial incentives and public reporting.18 In view of the importance of CCM and its lack of full implementation, the National Committee for Quality Assurance (NCQA) incorporated its measures into the standards and guidelines used to accredit the patient-centered medical home (PCMH) (see below). 19 MEDICAL HOME ACCREDITATION NCQA recognition as a PCMH is critical for two reasons: First, to ensure that the medical home contains the core components of the model, as well as demonstrates the key processes involved. Second, to provide the basis for payment mechanisms which recognize the value-added provided to patients receiving care from a medical home. 20 For most organizations, gaining recognition is a step-wise process. To briefly summarize, there are three (3) levels of accreditation based on a point system; Level 1 PCMH is the first level. The level achieved depends on the degree to which the PCMH has fulfilled the NCQA standards covering areas such as electronic medical record (EMR); registry and patient tracking; care access and communications; patient self-management; evidence-based guidelines; and, quality improvement.21 Aside from setting up a PCMH, these accreditation standards are too generalized to help medical homes that specialize in special needs patients with multimorbidities and are looking for targeted, evidence-based clinical models and interventions that fit their complex needs. MEDICAL HOMES AND PAYMENT REFORM There are two main reasons cited for medical home-related payment reform: 1) infrastructure support; and, 2) alignment of incentives for the provision of efficient, effective, quality care. Most current medical homes use a hybrid approach that includes standard fee-for-service (FFS) reimbursement for primary care office visits plus a monthly care coordination fee and/or incentive add-on payments (e.g., per visit). As indicated above, payment amounts are frequently related to the level of accreditation received by the medical home; the higher the PCMH level, the greater the amount.22 The hybrid form of payment sketched above is one of a wide range of payment models that have either been adopted by medical homes or are being explored as part of various public and private initiatives. Overall, there are eight (8) possible payment models:23 1. 2. 3. FFS reimbursement with discrete new codes FFS reimbursement with higher payments pegged to NCQA levels FFS reimbursement with lump sum payments pegged to NCQA levels

17 Singh, D. and Ham, C., Improving Care for People with Long Term Condition: A Review of U.K. and International Frameworks. Birmingham, UK: Health Services Management Centre, University of Birmingham, 2006. 18 Casalino, L. et al, External Incentives, Information Technology, and Organized Processes to Improve Health Care Quality for Patients with Chronic Diseases, Journal of the American Medical Association 2003; 289:4: 434-41. 19 National Committee for Quality Assurance (NCQA), Standards and Guidelines for Physician Practice ConnectionsPatient-Centered Medical Home (PPC-PCMH), 2008. 20 The development of medical homes go hand-in-hand with payment reform. As a result, the model is being increasingly linked to more rational and higher payments from both public and private payers. 21 For an excellent summary, see NYS Department of Health, New York State Medicaid Update: Announcing New York Medicaids Statewide Patient-Centered Medical Home Incentive Program, Special Edition, December 2009. 22 New York State, for example, pegs its incentive add-on payments to the NCQA accreditation level: $5.50/visit (Level 1), $11.25/visit (Level 2), and $16.75/visit (Level 3). Add-ons are associated with a constellation of mostly primary care CPT-4 codes for services provided by physicians and nurse practitioners. 23 Kodner, D., op cit.

p6 4. 5. 6. 7. 8. FFS reimbursement with PMPM care coordination fee FFS reimbursement with PMPM care coordination fee and pay for performance (P4P) FFS reimbursement with PMPY shared savings paymentsbased on audited return on investment (ROI) analysis FFS reimbursement with lump sum payments, P4P, and shared savings Risk-adjusted comprehensive PMPM (global capitation) paymentwith P4P.

It is important to note that with the exception of the global capitation option, medical home payment approaches do not generally adjust for patient characteristics. Such adjusted paymentwhether on FFS or capitation baseswould be especially helpful in enhancing the fit between medical homes and special needs patients with chronic, disabling, and complex conditions; more about this below. FITTING MEDICAL HOMES TO SPECIAL NEEDS POPULATIONS Special needs populations present a multiplicity of long term, chronic and disabling conditions with complex healthrelated needs that cut across the acute care, home and community support, and behavioral health systems. This broad category of multi-morbid patients includes the frail elderly, medically fragile children, and people with complex chronic illnesses, physical and developmental disabilities, and serious mental and behavioral health problems. While there are important differences between these various patient groups, on the whole they pose a number of clinical, service delivery and psychosocial challenges to the medical home model: These patients require more and a broader mix of health care and specialized services; experience greater levels of disability; are at higher risk for hospitalization and nursing home admission; often have burdened or frail family support systems; encounter unique challenges in accessing services; require more continuous, intensive and coordinated care; and, demand more time and effort to provide needed care overall. The fact that the medical home incorporates many of the practices of the Chronic Care Model does not guarantee an optimum fit. If the medical home is not properly designed, organized, staffed, and programmed, the challenges above can adversely affect its capacity to serve special needs patient populations. Therefore, we must pose the question: What needs to be done to make the medical home a more accommodating environment to provide comprehensive primary care services to these special needs patients? TARGETED, EVIDENCE-BASED CLINICAL MODELS AND INTERVENTIONS Over the past three decades, many clinical models have been developed and tested for patients with multi-morbidities. While many of these approaches have focused on geriatric patients, they are also generally associated with positive outcomes for patients in other special needs groups.24 Knowledge of these models and interventionsparticularly those that can be included under the rubric of comprehensive primary carecan assist medical homes in rounding out their capacity to serve the frail elderly and other special needs groups. Boult and colleagues have identified nine (9) such interventions:25 1. Interdisciplinary team care. Team carewhere providers from various disciplines manage patient care collaborativelyis one of the organizing principles of the medical home and a basic tenent of the Chronic Care Model. Studies show that inter-professional care can improve survival and quality of life (QoL), health outcomes, and patient satisfaction; it can also reduce overall physician visits, emergency department use, and hospital admissions, as well as lower costs. In addition to the primary care physician and nurse, team members may include the social worker, rehabilitation therapists, dietician, pharmacist, and others.

24 See Boyd, C. et al, Clarifying Multimorbidity to Improve Targeting and Delivery of Clinical Services for Medicaid Populations. Center for Health Care Strategies, December 2010; also Boyd, B. et al., Literature Review: Evidence-Based Models for Multimorbid Patients Not Specific to a Multimorbidity Pattern. Center for Health Care Strategies, December 2010. 25 Boult, C. et al, Successful Models of Chronic Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicines Retooling for an Aging America Report, Journal of the American Geriatrics Society 2009; 57(12):2328-37.

p7 2. Case/care management.26 In most forms, a nurse or social worker provides patients (and sometimes family members) with a combination of health assessment, care planning, education and counseling, and service coordination. Depending on program design, the involvement of the primary care physician in the case management process ranges from frequent to rare. Case/care management can improve patient satisfaction and QoL, enhance medication compliance, reduce hospital admissions and inpatient days, and enhance patient access to needed services (medical and non-medical) across time, place, and discipline. 3. Chronic disease self-management. Self management programs are structured, time-limited interventions designed to educate patients and empower them to assume an active role in managing their own chronic conditions. Programs, which can be professionally-led or facilitated by trained lay persons, focus on the management of specific chronic conditions (e.g., diabetes and heart failure) and/or address the risk factors more generally associated with chronic conditions. Chronic disease management programs for the non-elderly report improvements in QoL, functioning, and satisfaction, as well as fewer bed days and other clinical outcomes.27 4. Preventive home visits. Periodic home visits by nurses or other visitors help to monitor the patients health and functional status, and encourage self-care and the appropriate use of health care services.28 Research shows that preventive visiting improves QoL, functional autonomy, and survival, as well as reduces hospital and nursing home admissions. 5. Pharmaceutical management. Pharmaceutical management is an advisory service provided by the primary care team and/or the pharmacist to encourage the safe and effective use of prescription and over-the-counter medications by patientslike the elderlywho are on long term, multiple medication regimens to treat chronic conditions. Randomized trials demonstrate that this intervention can improve medication adherence, reduce medical symptoms, control blood pressure, and otherwise improve QoL. 6. Comprehensive outpatient assessment. Outpatient assessment of the patients medical, functional, behavioral, social and living circumstances is designed to present a comprehensive picture of the individuals health and psychosocial needs; this is a critical aspect of holistic care, especially for geriatric patients. Comprehensive assessment can have positive effects on health status and functional outcomes; it also enables the identification of needs beyond the narrow confines of medical care. 7. Proactive rehabilitation. As an adjunct to primary care, physical and occupational therapists provide outpatient assessments and interventions which help disabled persons to optimize their functional autonomy and address home safety and other QoL concerns. This can reduce pain and symptoms, decrease fear of falling, enhance activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and increase the chance of remaining at home. 8. Caregiver education and support. Led by social workers, nurses, rehabilitation therapists and other professionals, these programs are designed to help family caregivers of patients with chronic conditions such as stroke and dementia; services can include health information, counseling, training, and access to professional and community resources. Programs show that they can improve the mood and functioning of care recipients, delay or at least reduce nursing home admissions, and lower total costs of care.

26 There is an overlap between case/care management and care coordination. The latter is identified as a key component of the medical home. Some assert that case/care management is a targeted process that is part of general disease management, while care coordination focuses on the complete range of medical, behavioral and social support services which may or may not be covered by health insurance or the benefit packages offered by managed care organizations. For example, see Antonelli, R., McAllister, J. and Popp, J., Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework, The Commonwealth Fund, May 2009. The case/care management function typically used in geriatric settings and described in the work of Boult and colleagues above comes closest to the broader care coordination concept. 27 According to Boult and colleagues, most studies of disease management for the elderly are inconclusive, negative, or difficult to apply to the general elderly population. The implication is that more tailored strategies are needed. See Boult, C. et al., Guided Care: A New Nurse-Physician Partnership in Chronic Care. New York: Spinger Publishing Company, 2009. 28 Home visitsespecially by nurse practitionersare also useful when disabled and medical fragile patients need primary care attention, but cannot make an office visit. In contradistinction, the medical home model focuses on officebased care.

p8 9. Transitional care. Patients with complex chronic illnesses present major challenges at discharge; difficulties are frequently encountered in developing safe discharge options for these patients and subsequently following them to successful completion.29 Typically a nurse or advanced practice nurse helps to ensure a smooth transition between the hospital/nursing home and home setting. This includes making certain that appropriate discharge arrangements are put in place; working with the patient and family caregiver to ensure that all needed medications, equipment, and supplies are available, and that they know how to use them and who to call in an emergency; organizing followup care; monitoring the post-discharge home situation for several weeks; and, keeping the primary care physician updated on the patients status.30 These programs are successful in facilitating continuity of care, reducing hospital readmissions and total costs of care, and improving QoL. LEARNING FROM PRACTICE In addition to considering the range of targeted, evidence-based models and interventions described above, we can also learn how to make the medical home more special needs-friendly and -capable by examining successful comprehensive primary care programs oriented to specific patient groups. This section briefly examines two successful programs: X Guided Carean office-based, coordinated, comprehensive primary care model of nurse-physician collaboration developed and successfully tested by a team at Johns Hopkins University that focuses on older people with multiple chronic conditions at the highest risk of using substantial health care services; and, X Premier HealthCarea nationally recognized, multi-site NCQA accredited PCMH for patients with developmental disabilities (DD), which is sponsored by New York City-based YAI/National Institute for People with Disabilities Network. GUIDED CARE In Guided Care, a specially-trained registered nurse (Guided Care Nurse or GCN), based in a primary care office, works closely with 2-5 physicians and other members of the health care team to provide comprehensive, coordinated, patientcentered, cost-effective primary care to 50-60 multimorbid elderly patients who are at the highest risk of using health services heavily.31 The model includes eight (8) main components: 1) comprehensive, home-based assessment covering medical conditions, medications, functional ability, cognition, nutrition, physical activity, home environment, social support, and patient health care priorities and preferences; 2) evidence-based care planning through the use of a personalized Care Guide listing medical and behavioral plans for managing and monitoring the patients chronic conditions; 3) self-management of chronic conditions by referral to a free, local 15-hour chronic disease self management (CCSM) course;32 4) monthly proactive monitoring by the GCN with reminders generated by the EMR; 5) coordinated care facilitated by the GCN using the Care Guide as a coordination tool, and including all health care providers who treat the patient (specialists, ED, hospital, home health agency, rehabilitation facility, and nursing home); 6) smoothing of transitions by the GCN focusing most intensively on hospital transitions, as well as keeping the primary care physician informed of the patients status; 7) caregiver education and support provided by the GCN to family caregivers, including in-person and telephone assistance; and, 8) access to community resources facilitated by the GCN to meet patient and caregiver needs.

29 For a brief review of the issue, see Coleman, E. and Boult, C., Improving the Quality of Transitional Care for Persons with Complex Care Needs, Journal of the American Geriatrics Society 2003; 51(4): 556-557. 30 There are two successful transitional care models for geriatric patients: For The Care Transitions Program, see E. Coleman et al, The Care Transitions Intervention: Results of a Randomized Control Trial, Archives of Internal Medicine 2006; 166:1822-28; for the Transitional Care Model, see Naylor, M., Transitional Care for Older Adults: A Cost-Effective Model. LDI Issue Brief, 9(6): 1-4. 31 Boyd, C. et al, Guided Care for Multimorbid Older Adults, Gerontologist 2007; 47(5):697-704. 32 The widely used CCSM program was developed by Kate Lorig, RN, Dr.PH and her team at the Stanford University School of Medicine Patient Education Research Center in Palo Alto, CA.

p9 The randomized control trial of Guided Care demonstrates that model improves the quality of patient care33, family caregivers perception of quality34, physicians satisfaction with chronic care35, nurses job satisfaction36, and may reduce the use and cost of expensive health care services.37 PREMIER HEALTHCARE38 Premier HealthCare is a Level 2 PCMC which is licensed by the State of New York as an Article 28 Diagnostic & Treatment Center (D&TC). It was recognized by the federal governments National Council of Disabilities in 2009 as one of the countrys most innovative models of health care for people with disabilities. Premier HealthCare is part of YAI/National Institute of People with Disabilities, a New York City-based network comprised of seven non-profit health and human services agencies serving 20,000 people of all ages with developmental, learning and physical disabilities or delays. The YAI Network includes 450 award-winning community-based programs, and also provides national leadership and advocacy on the special needs of people with disabilities. The 12-year old medical home program, which is geared to the DD population, operates at six (6) certified sites in four of New Yorks five boroughs (Bronx, Brooklyn, Manhattan, and Queens); it sees more than 8,000 active patients each year, with an annual average of 100,000 patient visits. The medical home offers the advantages of a small group practice in addition to specialized back-up from a large academic medical center. Premier HealthCare receives funding predominantly from Medicaid; a relatively small amount comes from Medicare (for dual eligibles). Primary care physicians at the medical home are Premier HealthCare employees, and also receive special training in the treatment and care of DD patients. Because people with DD experience higher rates of secondary conditions than the general population, the program offers immediate access to a variety of other specialty care, including social work, dental, and nutrition services. Because of the complex medical, functional and psychosocial needs of the target group, Premier HealthCare not only benefits from the many community programs of the YAI Network, but also from strong, well-established links with medical specialists (e.g., neurologists) and providers of mental health, substance abuse, long term care services and supports, and other specialized DD services throughout the New York metropolitan area. When this is combined with the medical homes care coordination services, patients gain nearly integrated access to needed care throughout the continuum of health and human services. SUMMARY AND KEY POINTS While the medical home is offered as a mainstream initiative to improve the delivery and financing of primary care, perhaps its greatest potentialif properly designedis as a comprehensive primary care approach for multimorbid patients with chronic, disabling and medically complex conditions, including the frail elderly, people with HIV/AIDS, and various physical and mental disabilities. Although the medical home rests in part on the Chronic Care Model, this does not assure that it is adequately equipped to handle the many unique clinical and service delivery challenges of special needs patients. As this paper makes clear, additional elaboration will be needed to make the medical home more special needsfriendly and special needs-capable.

33 Boyd, C. et al, The Effects of Guided Care on the Perceived Quality of Health Care for Multi-Morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Control Trial, Journal of General Internal Medicine 2010; 25(3)235-42. 34 Wolf, J. et al, Effects of Guided Care on Family Caregivers, Gerontologist 2010; 50(4):459-470; also Wolf, J. et al, Caregiving and Chronic Care: The Guided Care Program for Families and Friends, Journal of Gerontology: Medical Science 2009; 64A(7):785-91. 35 Marsteller, J. et al, Physician Satisfaction with Chronic Care Processes: A Cluster-Randomized Trial of Guided Care, Annals of Family Medicine 2010; 8(4):308-15. 36 Boult, C. et al, Early Effects of Guided Care on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial, Journal of Gerontology: Medical Science 2008; 63A(3):321-7. 37 Boult, C. et al, The Effect of Guided Care Teams on the Use of Health Services: Results from a Cluster-Randomized Controlled Trial, Archives of Internal Medicine 2011; 171(5):460-6. 38 Program details were provided by Marco Damiani, Senior Director, Clinical & Family Services, YAI Network and Peter DellaBella, MD, Medical Director, Premier HealthCare.

p10 Our examination of the medical home model within the context of targeted, evidence-based interventions and models, as well as successful programs that have made a difference in the care of these vulnerable, complicated, high-risk groups suggests that the following elements should be incorporated: X Access to primary care physicians who are either specialized in the care of these special needs patients (e.g., geriatricians), have extensive experience in their care, or at least receive special on-the-job training; X Back-up by a very broadly defined inter-professional team that includes nurses, social workers, psychologists, nutritionists, rehabilitation therapists, and other professionals; X Availability of both in-office and at-home primary care, including preventive home visits; X Real around-the-clock coverage and crisis intervention capabilities; X Multi-dimensional assessment focusing on medical and medication needs, functioning (ADL/IADL), cognitive abilities, nutrition, physical activity, family and social support, living environment, and patient priorities/preferences; X Care coordination/case management processes capable of addressing a broad range of needs at a moderate to intensive level; 39 X Chronic disease management strategies tailored to the patient populations special needs, including the use of innovative, evidence-based coaching techniques to encourage active self-management and patient compliance with medical/health care regimens;40 X Proactive focus on rehabilitation to address patients everyday symptom and pain issues and falls concerns as an integral component of comprehensive primary care; X Ongoing pharmaceutical management geared to reducing polypharmacy, improving patient compliance, and reducing the misuse and side effects of medication; X Robust transitional care strategies to make sure that patients do not fall in the cracks, receive follow-up care when and where needed, experience fewer preventable rehospitalizations, and primary care physicians are kept in the loop; X Health promotion and patient/caregiver support to increase the patients knowledge about her/his condition, improve adherence to prescribed care, and actively support family caregiving; and, X Robust referral, care coordination, and communications linkages with the panoply of health, behavioral health, and community support providers to meet both the patients routine and more specialized care needs. Finally, these points bear mentioning: First, groups representing the various special needs populations may wish to consider following the lead of the nations pediatric and child care specialists who continue to be actively involved in critically examining how to enhance comprehensive primary careincluding the medical home modelfor children.41 Second, given the expanded formulation of the medical home that is described in this paper, it will be difficult, if not impossible, for solo or small-medium primary care practices to achieve this vision. The greatest opportunities will be found in larger medical groups, clinics, community health centers and federally qualified health centers (FQHCs), primary care case management programs (PCCM), integrated care programs (including Special Needs Plans or SNPs), and accountable care organizations (ACOs). Third, communities in which Medicaid-funded medical homes and health homes co-exist have the best chance of building effective primary care-oriented models for comprehensive special needs care.42 39 For an excellent discussion of the levels of care coordination, see Antonelli, R., McAllister, J., and Popp, J., op cit. 40 For example, the Guided Care nurse uses motivational interviewing approaches to encourage active patient engagement. For an excellent resource on motivational interviewing, consult Miller, W. and Rolnick, S. Motivational Interviewing: Preparing People to Change. 2nd. Edition. New York: Guilford Press, 2002. 41 The Commonwealth Fund, for example, has supported work to better understand and improve the care coordination process for at-risk and other children. 42 Medicaid-funded health homes must provide the following services: comprehensive care management, care coordination and health promotion, comprehensive transitional care, patient and family support, and referral to community and social support services. In New York, for example, interim health home provider qualification standards focus on

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Fourth, creating medical homes for special needs populations, many of whom are dual eligibles, face the difficult set challenges involved with stitching together the fragmented Medicare and Medicaid systems.43 And, fifth, risk-adjusted capitation can enhance the ability of special needs medical homes to provide the kind of comprehensive, accessible, high-quality, efficient primary care envisaged in this paper. Because this payment method reflects patient characteristics and their actual relationship with health services utilization and costs, such medical homes would receive a more appropriate level of support.44

*This paper was authored by Dr. Dennis L. Kodner and prepared with the support of the Author Webb Group, Inc. Dennis Kodner, PhD, FGSA is a global thought leader on health systems/services integration. He is an expert on coordinated care and managed care systems for people with chronic, disabling, medically complex, and high-risk conditions, including the frail elderly and those whose needs cut across the health, long term care, mental health, and social service systems. Arthur Y. Webb Mr. Webb has extensive experience in the policy and practice areas of serving high needs, high cost individuals. See www.arthurwebbgroup.com

chronic medical and behavioral health populations. Nonetheless, broader applicability is possible, including the DD and long term care populations. 43 For a discussion of the dual eligible dilemma and its implications for patient groups with special needs, see Kodner, D, op cit, 2010. 44 For a further discussion of risk-adjusted capitation financing, particularly for patients with DD, see Kodner, D., op cit, n.d. The paper includes a brief description of the Community Medical Alliance (CMA), which is part of a larger Medicaid HMO (Neighborhood Health Plan or NHP). CMAs specialized clinical program for individuals with HIV/AIDS, severe disabilities, and DD receives a sub-capitation payment from NHP; the rate for enrollees with AIDS and severe disabilities is risk adjusted.