The Story and the Ideals
Welcome to SETMA’s Medical Home “Story Book.” The contents are the thoughts, ideas and analysis of SETMA about Medical Home and particularly about our medical home.. Formally, our story began February 17, 2009 when we attend a lecture about Patient-Centered Medical Home (PC-MH). In reality, our medical-home pilgrimage began decades ago. The initial part of our story is organized into three sections, each of which represents articles written in the years 2009, 2010 and 2011. A primer to SETMA’s medical home is at: The SETMA Model of Care: Patient Centered Medical Home; Healthcare Innovation, the Future of Healthcare.
Perhaps the most creative initiative in the transformation of health care is the concept of PC-MH.. At a time when there is great pressure for "reforming of the healthcare system," few understand that it is only transformation which will ultimately make a permanent difference. Reform is brought about by external pressure from without to force conformity to someone else’s idea of what healthcare ought to be. Reform only works for as long as pressure is applied and it is often resisted. Transformation is driven by an internalized passion which is generated by principles, convictions and personal vision.
In 2010, SETMA was recognized by the National Committee for Quality Assurance (NCQA) as a Tier 3, Patient-Centered Medical Home and was also accredited by the Accreditation Association for Ambulatory Health Care (AAAHC) and as a Medical Home. In 2011, SETMA was reaccredited by AAACH for both for a three-year term. In 2013 SETMA renewed NCQA’s Tier III Medical Home for 2013-2016. This year, we are applying for URAC medical home accreditation and in 2014 in addition to renewing our AAAHC accreditation we will apply for Joint Commission medical home accreditation.
It is our hope that this material may stimulate others to start their own Medical-Home pilgrimage and that others will begin to collect their own Medical-Home stories. If so, then this notebook's purpose will have been fulfilled. These articles chronicle our development of a medical home. The developmental history of SETMA will show that as early as 1999, we began defining the principles of what would become SEMTA’s Patient-Centered Medical Home. After becoming a Medical Home, SETMA realized that without knowing it, we had spent over ten years developing the functionalities which enabled us to be a medical home.
Our caution to others comes from our own failure which was that initially we focused almost totally on the structures of medical home without understanding the dynamic and spirit of patient-centeredness. Our story will repeatedly illustrate and example the tension between the structure and dynamic of PC-MH.
These structural principles will only take SETMA so far in becoming a true medical home. The next step is a radical change in the dynamic of care, a dynamic which will address how medical colleagues related to one another and how they relate to those they serve. As will be seen below, five months after SETMA defined the structural changes needed for being a medical home, on October 1, 1999, we defined the new dynamic. Under the old model of care, which we might refer to as a paternalistic healthcare system, patients were very often told what to do and it was expected that they would follow the healthcare providers’ instructions without modification. The definition of “paternalism” helps understand the old model of care; it is: “A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities.”
The dynamic of the medical home redefines the relationship of healthcare provider and patient, and changes how they relate! Rather than the patient encounter being didactic (to lecture or teach, as one with knowledge instructions or informs those who do not) - where the healthcare provider tells the patient what to do, how to do it and when to do it - the patient/provider encounter becomes a dialogue (An exchange of ideas or opinions) - where the healthcare provider and the patient discuss a mutual concern and then together come to a mutual conclusion with a mutually agreed upon plan. This new relationship is somewhat like a partnership.
The following are significant examples of SETMA’s medical home pilgrimage:
How Our Healthcare System Evolved and How It Must Change: Patient-Centered Medical Home
Finally, the dysfunction in the healthcare system, which was created by innovations and advances, was recognized. Gradually, efforts were made to modify this system and to eliminate the dysfunction. Quality measures were published which allowed the care provided by one provider to be measured against the care given by another. Preventive care was emphasized, but remained difficult because preventive care was rarely if ever a primary reason for a patient seeing a provider and it was often not paid for by insurance companies including Medicare and Medicaid. As care evolved efforts were undertaken to move the patient back to the center of the healthcare equation. Providers began to be encouraged to emphasize preventive care and health maintenance rather than just dealing with acute illness.
The patient threatened to kill the next doctor who came into his hospital room but he didn’t expect to meet a friend with a stethoscope.
Anecdotal medicine is frowned upon as it is based on personal experience without the benefit of "random controlled" or "double-blind" studies. Anecdotal medicine does not allow for analysis to determine if the conclusions of the experience are valid or not.
However, in the case of Medical Home, while there is an objective standard against which to measure the essential functions of a Medical Home, it is the "stories" which are powerful. It is the "stories" which give breath (in this case we refer to respiration and life) and depth (in this case we refer to significance and validity) to the experience. In fact, SETMA would recommend that NCQA, AAAHC, the Joint Commission and URAC - currently, the four agencies reviewing Medical Home applications -- establish a "stories exchange." This would be a place where illustrates of successes in Medical Home could be shared with everyone. Each story will flesh out, in three-dimensions "real life situations," our understanding of what otherwise are two-dimensional abstract ideals such as "coordination," "Care Transitions" and "patient-centric," among others.
SETMA has a growing list of stories which in fact are the sign posts on our pilgrimage. We include only two here. One story is from the first day we started to think about Medical Home. The second occurred two days before this introduction was prepared.
SETMA’s conscious pilgrimage toward Medical Home began February 17, 2009 when five SETMA colleagues attended a medical home presentation in Houston, Texas. The meeting was disappointing but it stimulated SETMA’s studying the concept. In March, 2010, SETMA submitted an application to NCQA for recognition as a Medical Home. In July, we received a Tier III recognition. The following series of articles track that process.