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The Podium

Building medical homes

The waiting room is full, as it is most mornings at Boston Health Care for the Homeless Program’s main facility on Albany Street in the South End. The patient, an older-looking man with a baseball hat tugged down hard on his head, walks up to the front desk and says in a blunt, raspy voice, “I want to see a nurse on the orange team.”

And we thought, “It’s working!”

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Boston Health Care for the Homeless Program, which cares for 12,000 people each year, is one of the largest and oldest health care organizations in the country devoted to homeless people. As one of the 46 clinics and practices participating in the Massachusetts Patient-Centered Medical Home Initiative, a statewide multi-payer demonstration project organized by the Massachusetts Executive Office of Health and Human Services, the program’s main outpatient clinic has begun a transformation to the medical home model.

What is a “medical home”? In short it’s a model of care we’d all like to have access to. It is a systemic approach that identifies the individual receiving care as a member of a team of doctors, nurses, and staff — even the people at the front desk, who all work together for the best interest of the individual. It means behavioral health and primary health services are integrated, preventive services, like vaccination and cancer screening, are emphasized, care is coordinated across healthcare settings, decision-making is shared, and quality improvement is embedded in care delivery.

Since one of the main goals of the medical home is to have individuals view themselves as at the center of a team of caring providers, thus the “hooray!” moment when that patient asked for the orange team nurse.

HIV/AIDS, mental illness, substance abuse, trauma, emphysema and other smoking-related conditions and the terrible consequences of child abuse disproportionately affect the homeless. The health care needs of the homeless, their poverty — and homelessness itself — have a way of revealing the gaps in our health care system, maybe especially in a city like Boston with its crown-jewel medical schools and hospitals.

The problem of fragmented care isn’t limited to the homeless. One way or another, all Americans are affected by a health system that is unwieldy, inefficient, and expensive. Patient centered-medical homes aren’t a panacea — nothing is — but by coordinating and managing care at the primary care level, they promise to provide a solid foundation for health care that produces better outcomes at a lower cost.

How do we know that? Evidence from the Massachusetts Patient-Centered Medical Home Initiative and other demonstration projects are showing the potential. And look what has happened at the Boston Health Care for the Homeless. The program has had electronic health records well before the current push for them, and care coordination among multidisciplinary groups of providers has always been part of the mix. But the medical homes have created a more organized, sustainable structure. Teams huddle every morning to share information about patients scheduled to visit that day. Weekly “hotspotting” meetings focus on the five percent of patients with the most complex — often most expensive — problems. Walk-in patients — and there are lot of them — are seen by clinicians on their team, rather than by a separate service where there is no continuity. Quality-of-care measures are moving in the right direction: cancer screenings, depression screening, and vaccine rates are up.

This type of change isn’t easy; medical homes don’t just build themselves. UMass Medical School supports Boston Health Care for the Homeless and other participating practices in the statewide initiative with practice facilitators who provide on-site advice and guidance. The medical school also hosts conferences, webinars, online courses and other opportunities for shared learning to guide clinicians and staff through the transformation process.

In 2010, Massachusetts health officials set a goal for all primary care practices in the commonwealth to become patient-centered medical homes by 2015. The Affordable Care Act isn’t as ambitious, but the federal government is funding three large medical home demonstration projects. Meanwhile, private insurers are offering financial incentives to practices that adopt at least some aspects of the medical home because of evidence that they can cut cost and improve outcomes.

Health care is full of fads and mouthfuls of jargon to disguise them. Some may see patient-centered medical homes in that light. But in our experience, the medical home model holds great promise for improving health care — especially for people that need it the most.

Of course the irony of building medical homes for people without a real home to call their own is not lost on us. But by showing that medical homes work, homeless people may be teaching us something about how American health care might be reorganized so it’s more effective, efficient, and humane for all of us.

Dr. Jim O’Connell is president and a founder of the Boston Health Care for Homeless Program. Dr. Monica Bharel is the organization’s chief medical officer. Dr. Judith Steinberg is deputy chief medical officer for UMass Medical School’s Commonwealth Medicine division.
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