Building a medical neighborhood for the medical home.
Building a medical neighborhood for the medical home.
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DOI：
10.1056/nejmp0806233
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发表时间：
2008-09-18
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影响因子：
--
通讯作者：
Fisher ES
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作者：
Fisher ES
美国最近改善初级保健的努力主要集中在制定和实施旨在为患者创建“医疗之家”的实践模式和支付改革。医疗之家的概念具有直观的意义，确实有很大的希望。但是，人们对这一模式抱有不切实际的期望，而且对医疗之家模式在临床和财务上取得成功的几个重要障碍关注不够。医疗之家的概念最早出现在儿科学领域，当时人们认识到，有特殊需要的儿童将受益于一种有效协调许多患者所需的复杂临床和社会服务的交付模式。最近，代表主要初级保健专业的组织-美国家庭实践学会，美国儿科学会，美国骨病协会和美国医师学会-共同努力，发展和认可“以病人为中心的医疗之家”的概念，这是一种实践模式，将更有效地支持初级保健的核心功能和慢性病的管理。[1]该联盟还主张进行支付改革，以支持在当前按服务收费的做法中往往不能得到充分补偿的服务，例如在特定办公室访问的背景下进行护理协调，采用健康信息技术，以及通过电话或电子邮件与患者互动。目前正在测试的支付改革通常涉及对符合国家质量保证委员会主持制定的资格要求的做法按病人每月支付额外费用（见表1）。尽管最近宣布的一个示范项目侧重于单一综合交付系统的实践，但2大多数当前或计划中的项目只是在一个地区或州选择合格的实践。
Recent efforts to improve primary care in the United States have focused largely on the development and implementation of practice models and payment reforms intended to create a “medical home” for patients. The notion of a medical home makes intuitive sense and indeed has great promise. But unrealistic expectations about this approach abound, and insufficient attention is being paid to several important barriers to the clinical and financial success of the medical-home model.The concept of a medical home first emerged in pediatrics, where it was recognized that children with special needs would benefit from a delivery model that effectively coordinated the complex clinical and social services that many patients require. More recently, organizations representing the major primary care specialties—the American Academy of Family Practice, the American Academy of Pediatrics, the American Osteopathic Association, and the American College of Physicians—have worked together to develop and endorse the concept of the “patient-centered medical home,” a practice model that would more effectively support the core functions of primary care and the management of chronic disease. 1 The coalition also argued for payment reforms that would provide support for services that tend to be inadequately reimbursed in current fee-for-service practice, such as care coordination outside the context of a specific office visit, the adoption of health information technology, and interaction with patients by telephone or e-mail. The payment reforms currently being tested generally involve an additional per-patient monthly payment to practices that meet the qualification requirements developed under the auspices of the National Committee on Quality Assurance (see Table 1). Although one recently announced demonstration program focuses on practices in a single integrated delivery system, 2 most current or planned projects simply select qualified practices in a region or state.