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Perspectives on the Medical Home

What is a personal medical home? How can primary care practices today provide this medical home for their patients? How can different types of medical practices providing care to a number of different types of patients provide a consistent set of services?

These types of questions were posed recently to physicians participating in the TransforMED National Demonstration Project, a selected group of 36 medical practices that are working to transform to a new model of care.

Four unique individuals from very different types of medical practices responded...

What Makes a Medical Home?

David Loxterkamp, MD - Seaport Family Practice
Belfast, Maine

Web site: www.seaportfamilypractice.com
Self-directed NDP Group - Medium practices of 4-6 physicians

The Future of Family Medicine report identified the "family medical home" as the centerpiece for a New Model of personal medical care. But never defined it. Nor will a two-year study comparing Facilitated vs. Self-Directed Practices give us a final product. The concept of a medical home will likely evolve as an amalgam of family physicians' desires and abilities. My remarks are a small contribution to that gathering rubber band ball.

Like the needlepoint wall hanging reminds us, "Home is where the heart is". The meaning is not changed because I dropped the "h" from "hearth." Home is where people who know the value of human relationships gather to be nourished and care for others.

A medical home is not enlarged by horizontal integration, the so-called "basket of services." Nor is it improved by vertical integration, the ideal of continuous care from birth to death, or office to hospital to nursing home. These are neither sufficient nor necessary to create a sense of caring that family physicians bring to their patients and offices.

A medical home needs fiscal viability, just like our personal home.  It is more than a place where we earn our paycheck, just as our personal home is more than where we spend it. Homes can be broken by divorce and invigorated by communication, mutual appreciation and a sense of common purpose.  They are difficult to maintain because human relationships are always more difficult (and vastly more rewarding) than the mastery of machines.

Primary care physicians know that their patients just want to be happy. Freedom from disease is part of that. But since most diseases are chronic and all of us are destined to die, most of what we give our patients is reassurance, hope, encouragement, momentary relief from their suffering, and a relationship to help them feel connected.

We also know that is difficult for unhappy doctors to help their patients find happiness or realize that they deserve it. It is possible that learning a new procedure, or buying a new computer, or making another $10,000 will make us happier. But somehow- knowing that we all freely chose family medicine- I doubt it. Happiness cannot come from our patients, no matter how grateful they are. It does not flow directly from a sense of service or duty or success. It must come from somewhere within. And begins with a question, not unlike the one Howard Thurman, the civil rights activist and theologian, once raised, "Don't ask what the world needs. Ask what makes you come alive and go do it. Because what the world needs are people who have come alive."

Whatever the medical home becomes, it will be different things to different practitioners. We are alumni of varied training programs working in varied organizations and living in varied communities. We have different personal needs and ambitions. There is no administrative blueprint or business plan that can save us. There should be no judgment about who is or is not a genuine family physician practicing authentic family medicine. Let's not forget that the forces giving rise to our specialty were larger than our founders.  It would be folly to believe that the purity of our ideals or the brilliance of our conceptions could subdue the social pressures that are undermining medicine today. But this should not discourage us; we can all do our best. This is the real spirit of the Future of Family Medicine. As a patient of mine confided to me shortly before his death, "I just want to be the best George Littlefield I can."

We do not need more motivational speakers or change consultants. Let's each of us ask what makes us come alive, and go do it. The best we can.

"A Personal Medical Home"

Ramona G. Seidel, MD
Bay Crossing Family Medicine - Annapolis, Maryland

Web site: www.baycrossingfamilymedicine.com
Facilitated NDP Group - Small practices with less than 3 physicians

On a late summer Wednesday afternoon, I received a message from a parent volunteer (who happens to also be my patient) at a local church camp.  She said, "I am sending CS over to your office.  We think he has a broken arm and he is your patient.  His mother has been called, and she is on her way to your office as well."

It was quite clear when the 11 year old arrived in my office that he had indeed fractured his left forearm and would need radiologic confirmation as well as orthopedic attention.  I did a quick assessment, splinted the arm and began the process of arranging orthopedic consult late in the day.  By the time his mother arrived, around 5:30 p.m. we had an x-ray organized, as well as the follow up appointment for the next day at orthopedics. They were given instructions to await the "wet read" at the local radiology facility and I sent them on their way.  "Displaced distal ulna and radius fractures" was the report. I spoke with the orthopedist on call who advised this patient go to the ER for care. He agreed to meet the family there when the time came.  I called ER triage to let them know CS was on his way.

I received a call that night from the mother thanking me for "working your magic".  Apparently their waiting time in the ER was minimal and they were home shortly after 8 p.m.  (This is highly unusual in our local ER).

So, how does this speak to the medical home?   Later that week I was describing this episode to a family member (a non-medical professional) who wondered why the patient would have come to my office in the first place.  "Why wouldn't they have simply gone to the ER?" he asked.  I did not immediately have an answer to his question.  Later I realized that I am the "FIRST STOP" this patient would make because I am his family physician and in that I am serving as his medical home.  The family trusts me to care for him in any capacity I am able.

Five days later, the patient and his mother saw my car pull into my office parking lot and they followed it to update me on his condition.  Why?  Because, I am his family physician and they trust that I would be interested in the outcome of his condition.  I think that too speaks to the concept of a "Medical Home".

Perspectives on the Personal Medical Home

Dr. William Thomas
Indian Land Primary Care - Indian Land, South Carolina

Web site: www.indianlandprimarycare.com
Facilitated NDP Group - New Practice

I think a Family Physician should provide a personal medical home for patients. My patients clearly demonstrate a desire for a medical home that provides quality, dependable and safe medical care and advice in no one's best interest except the patient themselves. Just like my personal family, my patients seek help and care from someone they trust to provide them with advice they know is coming from someone whose only motive is to genuinely provide the best and correct help possible in a time of need. If I can't provide what is needed my patients should know without question that they can trust I will only recommend a colleague that I know provides that same level of care without consideration of any factor other than quality.

A medical home should not be just an office, as a home should not be just a house. I think most patients want a medical home where they feel secure and safe— a medical home where people care for them as individuals rather than numbers, diseases, or organs to be scoped, biopsied or removed. Family Physicians should be the doctors patients turn to for either simple or complex needs. Patients should have complete confidence that their medical home will offer advice that is only in their best interest versus the interests of any who might be self rather than patient centered.

Personal Medical Home — What It Means to Me

Bonita C. Toms, RN Clin III
Crossroads Family Practice - North Garden, Virginia

Web site: www.healthsystem.virginia.edu/internet/familymed/docs/crossroads.cfm
Self-directed NDP Group - Small practice with less than 3 physicians

When I think of a Personal Medical Home, it is helpful for me to divide and simplify this to sort out my perception of this concept. 

When I think of "PERSONAL", the following words come to mind: mine, ownership, individual, unique, intimate, voice, choice and sense of humor. 

"MEDICAL" evokes thoughts like: ‘conception to death' care, growth, change, aging, sickness/wellness, monitoring, screening. 

The term "HOME" brings to mind concepts such as: shelter, safety, warmth, comfort, acceptance without judgment, sanctuary, protection, permanence, caring, and empathy.  It also triggers thoughts like honesty, respect, leadership, guidance, wisdom, trust, and credibility.

As a Family Medicine nurse with greater than twenty five years of experience divided between two rural Virginia practices, I have a concrete idea of what I would LIKE my personal medical home to be.  In this era of managed care and abundant regulatory agencies, we often lose sight of our original purpose in the medical profession.  Patient care and service orientation are components of our work life that are harder and harder to uphold, but can and should be protected to the best of our ability.

As a patient, I want a medical provider who will walk with me on whatever path life leads me.  I want honesty, leadership, laughter, compassion, common sense and empathy.  When I enter the establishment, I want to be greeted by workers who tell me in their expressions that they want to be there, they are enjoying their work and are happy to see me.  I want to know WHO to talk to when I need help and I want to hear the caring in their voice.  I want an advocate when I am weak.   I want to feel secure in knowing that the person on the other end of the conversation (physician or support staff) really listened to our conversation and will follow through on my need.  If I have an unusual need, I want my provider (and staff) to identify all possible options and not quickly dismiss their need for involvement if it is unfamiliar or out of the ordinary.  I need to FEEL the warmth in their tone and touch at all times, even if I don't like what I am hearing.  I want to feel like a part of their "WHOLE", like I am part of their investment.  I want to be the benefit of thoughtful, clever resourcefulness when the need arises.  Last, but not least, I want safe practitioners.

As a member of the healthcare team, I believe that it is our right to hold onto whatever portion of "personal" we can in medical care.  It is my right, as a nurse, to "think outside the box" within appropriate boundaries.  I have been privileged over the years to work with a multitude of physicians both young and old, teachers and students.  One in particular changed my life as a nurse.  I watched her take a crisis patient's face in her hands, look him in the eye and say "You are in a safe place, we are going to take care of you"---he calmed right down.  What a powerful, non-medical statement!  That moment, I realized that many of the non-medical "RULES" I learned in nursing school did not always provide the best environment for feelings of security and comfort.  That encounter taught me to LISTEN to that "fleeting" thought that crosses my mind when dealing with people and consider them as instinctual or spiritual messages that allow us to often sense what our patients are feeling that they may not know how to articulate.

For the last twelve years, I have had the privilege of nursing in and helping build a new Family Practice in North Garden, Virginia which is a satellite clinic of The University of Virginia Department of Family Medicine.  This is a small practice of five physicians and two residents whose combined sessions amount to about two full time positions.  We have a support staff of two full time nurses, one part time nurse and two front office positions.  I have particularly enjoyed two aspects of this department and this practice: the size of the practice helps keep it personal and the trust and respect I have received here as the charge nurse has allowed me to help make this a personal medical home.  We have a unique combination of staff who are some of the most caring individuals I have ever met; "going the extra mile" is a way of life.   I truly believe that we are where we are meant to be "in the master plan" of life and that our patients sense that.  Our patients are comfortable asking for help and guidance here and feel secure that we will work with them until their problem is solved to the best of our ability

Many of our patients are served on a reduced rate, as this is a state supplemented hospital system. This is an income based sliding scale of payment, thus, we serve a wide economic range. The system is large and complex, navigating it is difficult for everyone, but especially difficult to those of limited exposure and resources.  We often serve as advocates for those who are unable to do so for themselves. One day, right at noon, one of our patients with a history of laryngeal cancer who used an artificial voice box for communication came in.  With a bit of effort on his part and ours, we learned that his voice box was not working and he wanted help to "fix it".  This is not exactly in the "Family Medicine" realm of service, but I sensed that he really struggled with communication and needed guidance.  I had no idea where to get him help, but I felt I needed to TRY.  I started with a call to the department that issued the device, was directed to the company and within thirty minutes there was a new unit on the way.  The appreciation in his eyes was worth all the effort.

We are located in the country, about ten miles from the hospital and the rest of University of Virginia clinical services.  One of my goals in both rural practices I have worked in is to offer as many services in the office as possible in order to make life a little easier on our patients.  We have disimpacted patients here in the office, drawn blood on infants, cut off wedding rings, drawn blood in the parking lot, given sponge baths and endless lists of other chores I have forgotten.  I guess it's my "country girl" roots that have given me the insight to really stretch our ability….as long as it's safe, I'm game!

The other part of this equation is the medical director of this practice, Andy Lockman.  Without his trust and support, we would not be able to do the things we do here.  I got a call at home one morning about seven a.m. from the daughter of a dying patient who lived about three miles from the office, but just across the hill from me.  We had previously disimpacted him in the office, but it was hard getting him here as he was mostly bedridden.  I called Andy at home, asked him if he would consider starting the day at this patient's home with me a half an hour before the office opened to take care of this; he agreed.  I came to the office, got all needed supplies and met him at the home and simply solved what could have been a major crisis for this family.  This was an elderly gentleman who was well known for this sense of humor.  Later, literally on his dying bed, he motioned for me to come close to him. His voice was faint and weak as he said, "That day you and Andy spent the morning with me was one of my favorite days!", then gave me a million dollar grin.

I know the attitude and personality of this practice has changed the lives of many people.  There is one Family Medicine physician practicing in this area who was ready to quit medicine when he came here as a second year resident.  He witnessed a different, more caring, more fun way to live in the practice of medicine and decided he just might fit after all.  During his two years here, one of his patients suffered a house fire.  As a staff, we pooled our donations and gave her gas and grocery gift cards to help her through this hard time.  That human bond will never be broken, never be forgotten.  We have multiple patients who have come here defensive and suspicious who have blossomed into smiles with a little personal, consistent care after never having been able to "connect" in other environments.

One of my personal goals and needs is to have a comfortable environment.  When we first opened, before we were connected to interpreters, we struggled to provide care to the large Hispanic population in this area.  Being off site, it is not easy to have an interpreter present for a visit and unpredictability of scheduling is a major issue.  Our waiting room could change from empty to full on a rainy day due to availability of transportation for migrant workers.  Tone, touch and expression are universally understood and although we often struggled to communicate, it was obvious they felt welcome and comfortable.  At one time, we had a two year old blind child and not surprisingly, he was quite anxious, loud and tearful.  It occurred to me that I had no power of distraction with this child, stickers meant nothing to him and he had clearly been "medically wounded" before we met him.  The first time he came here, I shared juice and cookies with him.  From that day on, he'd come in the front door saying, "I WANT COOOOKIES!"---life just does not get better than that!

As a nurse and person, I am very realistic and grounded.  Medicine is complicated and uncomfortable with all the regulations and fear of punitive legal actions at the drop of a hat.  The serenity prayer keeps coming to mind in thinking about this:

"God grant me the serenity to accept the things I cannot change,
courage to change the things I can and wisdom to know the difference."

I realize there are aspects of medicine that I cannot change.  We are never going to live without a zillion regulations, we must be wise enough to recognize and accept that.   We can, however, choose to have the courage to refuse to let go of the personal aspect of patient care.  Our patients have a right to be individually valued, respected, and enjoyed; that's the beauty of making a living basically "loving other people".  It is our right and responsibility to do our part in keeping medical care close to our hearts and providing quality "PERSONAL MEDICAL HOMES".