It’s ok to crawl before we walk

4 minute read

Small steps in the medical homes concept are fine, if they are in the right direction, suggests Prof Michael Fasher


As the Australian medical home draws closer, I talk to more and more colleagues who are convinced that primary health care in the US has gone to hell in a hand basket.

These critics of the patient-centred medical home are convinced and passionate.

One described his visit to an American centre. He was disturbed by the loss of relationships as he saw patients on a “conveyer belt” being trundled past members of “the team”. It is no surprise that, at this time of rapid change, quality will be uneven across the US.

But in the best centres, teamwork enhances the doctor-patient relationship by freeing doctors up from tasks that can be completed by others. Such tasks include ensuring the patient is receiving evidence-based care for their chronic or complex conditions. This allows the doctor’s time and energy to be devoted to the patient’s immediate concerns.

A senior colleague with good US contacts announced confidently that the implementation of the medical home there is a shambles and the movement is finished. Individual American colleagues are no doubt disturbed, dismayed and quick to report of a debacle.

It has long been true that in the US you get the very best and the very worst in pretty much every field of play. The “comfort zone” is an aptly named zone and only a few will enjoy being bumped out of it.

Another colleague asks, “What have we got to learn from the Americans? Their system is expensive; they have worse health outcomes. They should be learning from us.”

Australian health outcomes trump US health outcomes by any measure. This has more to do with the social determinants of health and the social determinants of disease than it has to do with the quality of the health systems in either country. A good place to explore these issues is this year’s Boyer lectures by Sir Michael Marmot, currently running on the ABC’s Radio National.

Australians are rightly proud of general practice in this country. Every day colleagues see that their work makes a difference. Despite operating in a fragmented health system and surviving on a shoestring, our best general practice shares many characteristics of the best US medical homes.

It is the answer to another question that distinguishes those who will be early adopters from the rest. That question is, do you think you could serve your patients better? If the answer is “yes”, then you are looking in the right direction. If you are making systematic improvements then you are moving in the right direction.

In western Sydney there are a collection of practices on the way to becoming better medical homes. Outcome data is systematically collected and used to drive quality improvement. They are able to report on the health of their practice population. The first cohort of receptionists is studying to qualify as medical assistants. The integrated-care demonstrator program is connecting up general practice and the wider health system.

This is laborious work at present because of the primitive tools at our disposal. In the best US medical homes, the process of data collection and analysis is seamless and, importantly, effortless.

To achieve this, high quality IT is needed. We require IT that connects the whole health system. There are US systems in which a patient’s electronic care plan is available at every point of care.

We won’t get to this level of sophistication quickly. Speed is not the point. It is crucial that all players and funders commit to the goal. Mini steps are fine, as long as they are steps in the right direction.

The essence of the patient-centred medical home can be distilled down to two elements.  High-quality teams in which relationships flourish, supported by high-quality electronic health plans developed in collaboration with patients. Both the teams and the IT have to be developed in parallel. Neither can function without the other and both need adequate investment.

For example, it has taken the South East Texas Medical Associates well over a decade to become the light on the hill that they are today. And as their leader Dr James “Larry” Holly says: “It is important to celebrate every small success. Beware discouragement – no one looks at a newborn and becomes depressed because she cannot walk.”

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