The medical home: What is the urologist's place?

Although the process of developing and implementing the PCMH focuses on the role of primary care physicians, it has implications for every physician. Urologists need to be mindful of how the PCMH emerges and how they can effectively work with the model to ensure coordination of care and quality outcomes for patients with chronic urologic conditions. The joint principles of the PCMH, as described by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association, include:

Personal physician. Each patient has an ongoing relationship with a personal physician trained to provide first contact and continuous and comprehensive care.

Whole-person orientation. The personal physician is responsible for providing for all of the patient's health care needs or taking responsibility for appropriately arranging care with qualified providers.

Coordinated and/or integrated care. Care is made available across all elements of the health care system.

Quality and safety. Patients are actively involved in decision making, using evidence-based medicine and clinical decision-support tools.

Enhanced access. Effort is made to enhance availability and communication between patients and their personal physician.

Payment. Compensation for care should take into account the added value provided to patients who are treated in this model.

Defining the urologist's role

In 2007, the Council of Subspecialty Societies of the American College of Physicians established a work group to address the perceived relationship between the PCMH care model and specialty/subspecialty practices. The group released a clarification document to respond to frequently asked questions (Chest 2010; 137:200-4).

The PCMH model, the council explained, provides no incentive to limit appropriate referrals to specialists by the personal physician-it is not a gatekeeper model. It does not prohibit patients from choosing to see a urologist or other specialist of their choice. The incentives of the PCMH are aligned to facilitate communication and coordination of care between the personal physician and the referred-to specialists, such as a urologist.

This model is most compatible for primary care practices, but is neutral as to the specialty of physicians providing the care as long as the practice meets all of the following criteria:

The PCMH 'neighbor'

The effectiveness of this model to promote coordination of care depends on the availability of the specialist and a hospitable and high-performing medical community, or "neighborhood." This requires reform in other provider entities-specialists and subspecialty practices-to align with critical elements of the PCMH to improve quality and generate the anticipated savings attributable to the PCMH model. To this end, members of the work group have suggested the possible development of a "neighbor": a specialty or subspecialty practice that effectively works in conjunction with PCMH practices to enhance coordination of care, improve consultations and co-management, and create seamless transitions for patients moving through different components of the health care system. This is relevant for treating urologic conditions and reflects other quality measures that improve access, facilitate patient communication, and seek better outcomes.

What's next?

The PCMH care delivery model has generated substantial interest and support over a short period of time. Yet, many critical questions remain, including: Which of the model's elements are most crucial to ensure improved clinical quality and efficiency? How will this model effectively provide an incentive for practices to deliver this form of care?

The answer to these and other relevant questions will be further addressed in demonstration projects being planned and implemented across the nation. Interface with the medical home and the urologist (and other specialists) clearly requires further definition and development.

Input from interested stakeholders is essential to ensure that the issues and challenges identified in this care model are addressed through collaboration and consensus based on available evidence.

Information on how the PCMH model continues to progress (and change) over time will be important to follow. Urologists need to keep their antenna up by following information available through reliable sources such as the ACP and the AUA, both online and in printed materials. The more information you have, the more information you can give to ensure the medical home and the coordination of care between the PCMH and the urologist yields the best clinical outcomes for your patients.

Judy Capko is a health care consultant and the author of Take Back Time- Bringing Time Management to Medicine . She can be reached at 805-499-9203 or judy@capko.com