President's Message

Flexible Leadership of the Patient-centered Medical Home

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President Mary Chesney, PhD, RN, CPNP, FAAN

Dear NAPNAP Members,

In my final few President’s Message blog posts, I’d like to share some thoughts with you about issues I see as being important to the future of health care and our current and future nurse practitioner practice. One such issue is flexible leadership of the patient-centered medical home (PCMH), a.k.a. health care home. A number of medical professional groups including the American Medical Association (AMA) and the American Academy of Pediatrics (AAP) have gone on record to state that physicians should lead all PCMHs. As patient advocates, I believe we must challenge their claim. In today’s blog, I provide rationale for this challenge and encourage you to let your voice be heard on this issue by submitting a comment to my post.

Much of the initial work in developing the PCMH concept in the early 1990s was accomplished by our pediatrician colleagues at the American Academy of Pediatrics. A number of NAPNAP members served on AAP workgroups or panels developing the PCMH concept. Since that time, and particularly since the inclusion of medical home demonstration models in the Affordable Care Act, the model of PCMH has been front and center in healthcare reform discussions. According to the Agency for Healthcare Research and Quality (AHRQ, 2015), the PCMH is a primary-care model that is comprehensive, patient-centered, coordinated, accessible, high-quality and safe. AHRQ further defines patient-centered care as “relationship-based primary care that meets the individual patient and family’s needs, preference, and priorities” (AHRQ, 2015, para 1).

So, why do I challenge the idea that a physician should always be the leader of a PCMH?

To make the assumption that a physician should always lead the PCMH is to ignore the definition of what it means to be patient-centered. If we are to focus on relationship-based primary care that best meets the needs, preferences, or priorities of patient and family, we need to acknowledge that sometimes nurse practitioners can best meet patient and family needs. NPs excel in patient education, relationship-based partnerships with patients and families, health promotion, and addressing environmental or contextual challenges to a patient’s healthy lifestyle or optimal management of chronic disease. Sometimes, due to patient instability or disease complexity, the physician is in the best position to lead the PCMH. For example, it seems appropriate for a pediatrician to lead the PCMH for a child with newly diagnosed leukemia, or a child with difficult to control chronic disease accompanied by complex co-morbid issues, periods of instability, or diagnostic dilemma concerns that warrant ongoing complex testing or pharmacologic management. In this scenario, the PNP may serve as a team-member to help coordinate care, see the child for interval visits, provide a symptom-management consult, or assist the pediatrician as necessary to meet the needs of the child and family. In contrast, it seems similarly logical for the pediatric nurse practitioner to lead the PCMH for a child or adolescent with a stable chronic condition, whose family is struggling to manage or cope with her condition due to lack of support, need for ongoing family education, social environment complexity or other contextual factors. In this type of scenario, due to his/her nursing perspective, knowledge and skills, the PNP may be the very best fit for the family’s needs and priorities. In this situation, the physician may best serve the team in a consultant-as-needed role, freeing physician time to focus on patients warranting complex diagnostic or management expertise.

Another reason for support of flexible team leadership of the PCMH based on the needs of the patient is that it promotes effective, efficient use of team members to best fit the patient’s situation. Healthy, stable infants, children and adolescents, and their caregivers are most often in need of nursing care, not medical care.  They need health promotion education about normal growth and development, healthy nutrition, sleep hygiene, and management of everyday childhood illnesses and injuries. They need anticipatory guidance to promote safe environments and practices, prevent illness and injuries, and foster appropriate social development and behavior through positive parenting. These healthy children need expert management of minor acute illnesses, health and developmental screenings to rule-out problems, and timely immunizations. These are all nursing care elements that can be delivered expertly by nurse practitioners. Fortunately, most children do not require complex diagnostic testing, complex management of unstable conditions, or present with diagnostic dilemmas. If or when they do, a flexible approach to PCMH leadership allows for a leadership change that best aligns with patient/family needs/priorities.  Flexible team leadership of PCMHs correctly places emphasis on patients’ needs rather than providers’ desires for power, turf or hierarchy. 

Why is this issue a health policy concern for NPs?

As more states consider legislation for new models of care or consider reimbursement for care coordination delivered in a PCMH model, NPs are frequently excluded as providers who can lead a PCMH or receive reimbursement for team-based services.  This type of provider discrimination limits NP practice and patient access to NP care. Another issue of concern is that a number of state legislatures have begun to consider organized medicine-led legislation to mandate physician leadership of PCMHs or mandate that NPs practice in physician-led healthcare teams.  For the reasons I’ve already mentioned as well as current and worsening primary care physician shortages, these legislative initiatives represent flawed, unsustainable healthcare policy that is not evidence-based.

What is your opinion about leadership of PCMHs?

I’m interested in your thoughts on this issue. Do you agree or disagree with my challenge of physician-only PCMH leadership? Are you experiencing legislative problems in your state related to this issue? Please share your ideas by posting a comment on this blog.

Yours in health,

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