[NPInfo] Re: [NP-Clinical] The "Medical Home" concept

Sat Sep 22 18:42:11 PDT 2007

Moriah,

  You raised many excellent scenarios and points.  I feel that patients do need a medical home. But I feel that the environment of the  "home" varies with the needs and illnesses of the patient.  The fact of the matter is how do you define "medical home"?  Is it a place that is large, and has lab, and white walls, and there are doctors there, and multiple ancillary staff, and a large front desk?  Or is it a cozy small place, that sees both same day appointments, regular scheduled appointments, housecalls, and yet is 500 sq feet, one or two personnel, and the overhead is low? But the functions are the same. The provider is maybe not a doctor, but has referral networks set up, to call optometry cardiology, nephrology, ent, or the ED if necessary etc, and get that patient in, with those small town feel personal touches. Seeing the patients on weekends and evenings, and getting to know the family members. Immunizations are given, patients can keep their large charts at home,
 and pertinent records are kept in the office, along with an ehr for the acute visits and other things scanned.  

  I feel that yes, patients do need a pcp to be the hub of the wheel and all of the episodic and specialist visits are the spokes, and someone needs to be "coordinating" all of this. But I do think there can be a widened perspective of what people call "the medical home"..Where would you want to go? 

  The places that I have seen that are traditional practices that would be called "medical homes' are not the places I would want to "live" in as a home. Sterile, de personalized, too many personnel to remember who you are or care, and many medical mishaps, mistakes, polypharmacy, and not coordinating the care of other specialists that the patient has been referred to. Then when there is a true crisis, and the patient is very sick/injured or dying, the "home team" suddenly is not around. A stranger, called a hospitalist, now steps in, and either makes mistakes, or disparaging comments, but at the least gets the history wrong, has to start all over, often cannot or does not want to call the "primary' who does not want to bothered. Is this a home?  Yes, Retail clinics serve a great purpose, no they are not the entire answer. But for 10 -20% of the population, they may be the right answer at that particular time. Carla/Oregon

David Mittman <dmittman at comcast.net> wrote:
  Moriah: What great questions. I think that there is so much truth that it
overlaps but that it also contradicts itself.

Truth: Patients need a medical home. Retail clinics say they are NOPT there
to provide ongoing primary care.
Truth: Physicians are accurate when they say that retail clinics fragment
care. So do urgent clinics and ER¹s.
Truth: Patients need a place to provide urgent care besides the ER.
Truth: Many people do not have a medical home
Truth: Many people can not afford a medical home.
Truth: Many people do not have insurance.
Truth: Physicians have not embraced any way to provide care to the above
segments.
Truth: PAs and NPs are great at providing care.
Truth: Big business is coming in to provide this segment of care
(unaffiliated patients) to people.
Truth: Big business may look at both patients and NPs and PAs as a commodity
in the end? Who knows there is no track record.
So, God only knows what it all means.
Dave

Truth: On 9/20/07 8:51 PM, "moriah mahoney" wrote:

> I am interested to hear from people who work/have worked in "Retail" settings
> about this concept of preserving the Medical Home and how retail clinics
> affect this. I support the further development of the NP and PA role in
> retail/urgent care clinics and clearly see a need in todays health care
> environment. 
> Do retail clinics/urgent care providers order testing that requires follow up?
> Do you counsel patients on the importance of a medical home? Do you see
> patients you wish you had a medical history or medication list on and spend a
> long time tracking down missing information?
> My thoughts are provoked by a slow clinic day due to heavy rain - not too
> common here in the high desert - and a couple patient encounters - one where
> the PCP sent the patient to the urgent care for a chronic issue that the PCP
> is aware of presumably because he didn't want to deal with it and another who
> was offered a PCP visit at 2:00 same day but was seen here at noon so she
> wouldn't have to wait - but didn't have school or work to consider and didn't
> seem to have other major considerations and had insurance.
> Maybe the discussion on retail clinics doesn't really relate to rural health
> care because the demographics are so different and the retail clinic seems to
> be a phenomenon of urban health care. But urgent care clinics are here in
> this area of rural New Mexico (staffed mainly by NPs and PAs sometimes by MDs)
> filling gaps in health care and presumably making money for the owners
> I work in a private practice urgent care office two days a week and sometimes
> evenings and weekends. I feel like for about 20% of the patients the option
> to come here was a timely and important option that contributes to a positive
> health outcome and their options at the time of the visit are generally
> limited due to severity of symptoms and/or time of visit. This is a small
> town with a several family practice and internal med clinics, a handful of
> specialists and another private practice urgent care, also a 50 bed hospital
> with 24 hour ER. Neither urgent care has X Ray or other diagnostic services
> beyond urine dips, rapid strep/flu, glucometers, nebulizers - pretty basic
> levels of care. 
> The urgent care is the medical home for so many people - especially the
> uninsured and those who don't perceive the need for routine medical care.
> Also recently those left in limbo if a PCP closes a practice (3 in the past
> year) In our town they might have to wait 2 weeks for a new patient visit in a
> primary care clinic, most of the long established practices no longer accept
> new patients. 
> There are a high percentage of patients seen by urgent care with minor
> symptoms within 24 hours of onset that I'd say could be managed by telehealth
> nurse triage and that is available 24hours a day. Some people come in and get
> some great medical information and advice but don't have a huge medical
> necessity - so might have been equally served by an appointment with their
> PCP. 
> I'd say at least 10% need to be either at the ER or are lacking follow up on
> (serious) chronic issues and in general they are not getting the necessary
> treatment and/or follow up at the urgent care clinic but they choose to visit
> urgent care over their PCP for a variety of reasons - ablility to pay is an
> obvious one but we do have an FQHC also in the town that is recently well
> staffed - had some hard times with provider retention in the past couple of
> years. 
> Some of the local providers see as many walk ins as they can and some refuse
> to see any walk-ins - practitioners who come here might be told by the
> hospital or other employers that they don't really need to see walk ins due to
> the availability of two urgent care clinics and the ER but of course in a
> small town it is hard to build up enough encounters to pay all of the
> overhead. Yes - some of the PCP offices are not too busy.
> It is hard to uphold continuity of care if you don't do any of the urgent care
> visits for your patients. Communication lines are open but not always active
> among the provider community.
> I always feel great about my role as an NP. I do sometimes feel concerned
> that urgent care that lacks continuity of care happens alot in my town. I'm
> curious to hear anyones questions, comments or remarks.

_______________________________________________
NPInfo mailing list
NPInfo at nurse.net
http://lists.nurse.net/mailman/listinfo/npinfo
*****************************

Carla R. Anderson, FNP-C
  Healing Presence Family Practice, PC  
  carla_rayne at yahoo.com
  503 819 9726