The term “medical home” may not be familiar to all health care providers, but the concept has been around since the American Academy of Pediatrics coined the term in 1967. It refers to a personal approach to a patient’s health, with a physician coordinating a team of professionals who take on the responsibility for that patient’s ongoing care. While it was first implemented for children with special health care needs, this concept was later adopted (2007) by the American Academy of Family Physicians, the American College of Physicians, and the American Academy of Pediatrics. Now the “Patient-Centered Primary Care Collaborative”¹ is an active organization representing multiple stakeholders, including physicians, employers, national health plans, and patients, who are trying to advance this concept.

Basic principles of a Patient-Centered Medical Home include:

• A personal physician for each patient
• A physician directed medical practice collectively taking on the responsibility of patient care
• A whole person orientation
• Care is coordinated and integrated across all elements of the complex health care system

Important elements that help build this foundation include:

• Optimal quality and safety
• Enhanced access to care
• Payment that appropriately recognizes the added value of a patient-centered medical home

The Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain² recommend identifying a medical home for patients on chronic opioid therapy, not necessarily to prescribe the chronic opioid therapy, but to coordinate consultation and communication among all of the involved clinicians. At the same time, the medical home clinician should identify when a patient needs further consultation or resources that the medical home cannot provide, and refer these patients appropriately.

In the best of all possible worlds, everyone should have medical home, a place to go for trusted medical advice without becoming lost in paperwork, authorizations, and red tape. Patients with chronic pain often have co-morbidities and multiple complex medical needs that require a great deal of attention. Currently there are medical home pilot demonstration projects serving adult patients in 18 states, involving collaboration with health plans and health care providers, to test out their feasibility. In addition, there are a number of pilot demonstration projects sponsored by the public payers, Medicare and Medicaid. There are further medical home initiatives for pediatric patients. They all share the goal of improving patient outcome while reducing the cost of total health care spending.

When to obtain consultation

There are many reasons that a clinician may decide to seek consultation for a patient with chronic pain. It is always important for the patient to understand the reason for the consultation, and to have an understanding of the provider’s role in their continuing care. Major reasons to request a consultation for a chronic pain patient include:

• Medical management is thought to require specific expertise beyond the provider’s scope of clinical practice. This may include patients who have had a poor response to treatment, patients who are candidates for opioid therapy, but their risk assessment reveals them to be at higher risk and in need of more monitoring than is available, or a patient with specific co-morbid conditions, such as a psychiatric disorder needing coordinated care.

• A comprehensive, multidisciplinary assessment is necessary. A diagnostic assessment or long-term management plan needs to be developed with the consultation of specialists from several disciplines.

• An interventional approach is thought to be necessary. At times minimally invasive procedures such as epidural steroid injections, nerve root blocks, facet injections, nerve stimulators or infusion pumps may be indicated for diagnostic or treatment purposes.

Identifying a need for a consultation does not mean that the provider relinquishes the coordination of care, but will continue to accept primary patient-care responsibility.

References

1. Patient-Centered Primary Care Collaborative, www.pcpcc.net
2. Chou R, Fanciullo GJ, Fine PG et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal Of Pain: Official Journal Of The American Pain Society 2009;10(2):113-130.