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Primary Care

Patient-Centered Medical Home plus TCM

The Patient-Centered Medical Home (PCMH) has emerged as a popular, and promising, model of coordinated primary care. Although results thus far are mixed, the PCMH is designed to improve patient outcomes by coordinating care of complex patients across clinicians and settings. One challenge for PCMHs and other advanced primary care approaches is poor communication with acute and post-acute care sectors. Integrating the TCM into the PCMH model could help to address these system challenges. With the support of the Hillman Foundation, the Gordon and Betty Moore Foundation, and the Jonas Center for Nursing Excellence multiple foundations, we partnered with primary care practices in Southeastern Pennsylvania to design and test an intervention that augments the PCMH with the TCM.

This innovative model stresses prevention of avoidable emergency department visits and hospitalizations and allows for continuous care management of patients across settings of care. The combined PCMH + TCM included four key elements:

  1. coordinated care across an episode of acute illness throughout a variety of settings (e.g., a transitional care nurse (TCN) meets with patient/family caregiver in hospital, or sees patient in the home within 24 hours of transition, and updates the PCMH provider);
  2. active engagement of the patient and/or family caregivers and TCN in development of plan of care;
  3. a collaborative partnership between the patient/family caregivers, the TCN and PCMH clinicians; and
  4. coordination of education and community services to develop self-management skills.

Hirschman and colleagues confirmed the feasibility of adapting and implementing this combined care innovation in five PCMH sites in southeast Pennsylvania. Early results indicate that compared to the PCMH only group, the PCMH+TCM group demonstrated improved emotional health and quality of life, as well as increased time to first rehospitalization or death.