PracticePerspectives

The Medical Home Model:What Is It And How Do Social Workers Fit In?

10IS S U E

A P R I L2 0 1 1

BackgroundThe “medical home” concept dates to the late1960s and has, until recently, been confinedlargely to the pediatric community. However,in the health reform era, the concept is beingembraced as a model of health care deliverythat is comprehensive and cost efficient,particularly for people with complex healthconditions. Medical home programs aregrowing rapidly, fueled by interest from boththe public and private sectors. The hallmark ofthe medical home is integrated, multi-disciplinarycare that meets a patient’s physical andbehavioral health needs. The AffordableCare Act of 2010 advances a systems-levelmanifestation of the medical home—the“accountable care organization” (ACO)—a health care delivery model intended topromote shared accountability for improvingpatient care and controlling costs for adefined population. Social workers arewell positioned to participate in these healthdelivery models – and have demonstratedtheir value in many of the medical homedemonstrations projects currently underwaythroughout the nation.

What is a medical home?At its most fundamental, a medical homesuggests an on-going relationship between anindividual and his or her primary care team.A medical home provides care that ispatient-centered, team-based, comprehensiveand coordinated. The Agency for HealthcareResearch and Quality (AHRQ) suggests that amedical home is not just a place, but a modelfor organizing primary care that meets thelarge majority of a patient’s physical andmental health care needs, including preventionand wellness, acute and chronic care (AHRQ,2010). A medical home provides carethrough an interdisciplinary team, composedof physicians, advanced practice nurses,physician assistants, nurses, social workers,and pharmacists. Some medical homes willemploy diverse teams directly; others will buildvirtual teams, linking themselves and theirpatients to providers and services in theircommunities. Medical homes vary in size fromsmall (physician practices) to mid-size (safetynet providers such federally qualified healthclinics and free clinics) to large scale (e.g.,non-profit health systems and the Departmentof Veterans Affairs).

Stacy Collins, MSW

Senior Prac t i ce Assoc ia te

sco l l ins@naswdc.org

ProfessionalDevelopment

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Practice Perspectives Issue 10 April 2011

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Workforce Studies & Reports available atWorkforce.socialworkers.org/studies/other.asp• Criminal Justice Social Work: Adapting to New Challenges• Child Welfare Social Workers’ Attitudes Toward Mobile

Technology Tools: Is There a Generation Gap?• 2009 Compensation & Benefits Study: Summary of Key

Compensation Findings

Social Work Practice Updates available atSocialWorkers.org/practice/default.asp• 2010 Medicare Changes for Clinical Social Workers• A Shift in Approach: Addressing Bullying in Schools• Biopsychosocial Challenges Related to Transitions of Care• Clinical Social Workers Be Aware: The ICD–10–CM is Coming• Delivering Culturally Appropriate Care for Older Adults• Enrolling In Medicare as a Clinical Social Work Provider• From Poverty to Child Welfare Involvement: The Critical Role

of Housing in Family Stability• MDS 3.0: Implications for Social Workers In Nursing Homes

and Community-Based Settings

• Medicare-Mandated Reportable Changes for Clinical SocialWorkers in Solo or Group Practice

• Meeting the Challenge of Supervision in School Social Work• Meeting the Needs of Immigrant Children and Youth In Child

Welfare• Part II: Advocating for Change in Home Health Care• Pharmaceutical Industry Prescription Assistance Programs:

Benefits and Challenges• Results of Request for Compelling Evidence to Increase

Psychotherapy CPT Codes• Social Work and Transitions of Care• Social Workers: A Bridge to Language Access Services• The Childhood Obesity Epidemic: The Social Work Response• The Economic Downturn: Implications for School Social Work• Trends in Medication Adherence• When A Clinical Social Worker in Solo or Group Practice Dies• Women and Domestic Violence: Implications for Social Work

Intervention• Youth Aging Out of Foster Care: Supporting Their Transition

into Adulthood

Center for Workforce Studies & Social Work Practice Recent Publications

WKF-NL-80811.MedicalHome:TC9990301-LAYOUT-MQ1.qxd 4/12/11 1:06 PM Page 1

Barriers toexpansion of themedical homemodel

• An estimated 65 million

Americans live in officially

designated primary care

shortage areas. Although the

U.S. spends more on specialist

care and has more specialists

per capita than any other

leading industrialized country,

the number of medical students

entering internal and family

medicine residencies is

steadily declining.

• Coordination between primary

care physicians, specialists,

and hospitals is often lacking;

each of these health care

providers is often unaware of

the others’ treatment plans.

• Current fee-for-service and

procedure-based payment

systems that dominate much

of U.S. health care benefit

doctors and specialist

physicians (Project

HOPE, 2010).

• For vulnerable populations,

health promotion and disease

self-management education

are as important as medical

coverage and enrollment.

However, current health policy

allows no reimbursement

mechanism for these services

(Tataw, 2010).

Unique Features of The MedicalHome Model■ Use of Meaningful Performance measuresCurrent medical home demonstration projects –as well as payment models for ACOs - are usingkey performance measures to gauge theireffectiveness. These include:

• Reducing 30 day hospital re-admissions• Delaying permanent nursing home

placement• Reducing avoidable emergency room visits• Increasing access to primary care• Improving patient satisfaction• Decreasing health disparities.

Early evidence suggests that medical homes havethe potential to improve quality and reduce costs.Among vulnerable populations, medical homeprograms are showing improvement in access toprimary care and reductions in avoidableemergency department utilization (Grumbach,2009). Demonstration projects involving socialworkers (see below) are also showing positivetrends on many of these measures.

■ Emphasis on Care Coordination andInterdisciplinary Teams

An essential feature of the patient-centeredmedical home is care coordination. AHRQdefines care coordination as “the deliberateorganization of patient care activities betweentwo or more participants (including the patient)involved in a patient’s care to facilitate theappropriate delivery of health care services”(AHRQ 2010). Care coordination is central tothe shift in orientation away from a focus on

episodic acute care to a focus on managingillness and facilitating preventative self-care,especially for those living with chronic healthconditions (NCCBH, 2009). Within a medicalhome, teams of health care professionals fromdifferent disciplines and practice areas shareresponsibility for managing key components ofpatient care.

The interdisciplinary team approach offersopportunities to improve care and lower costs,especially for patients with depression, physicaldisabilities, and other conditions that haveproven difficult to treat in primary care settings(Commonwealth Fund, 2010). Team-based carealso frees up physician time—as responsibilitiesshift to other staff members—and promotes a workenvironment where all staff can practice at thehighest level their licensure or certification allows.

■ Integration of Behavioral Health intoPrimary Care

Most mental health problems first emerge inprimary care settings; for many vulnerablepopulations, primary care is often the only sourceof mental health treatment. Rates of mental healthproblems are significantly higher for patients withcertain chronic conditions (e.g., diabetes, heartconditions, asthma). Failure to treat both physicaland mental health conditions yields pooreroutcomes and higher costs. (NCCBH, 2009).Although not consistently integrated into allmedical homes, behavioral health—throughco-location or referral protocols—remains animportant component of the medical homemodel (Blount, 2011).

What do social workers offer to themedical home team?Social workers can provide valuable functionson a medical home team, including:• comprehensive assessment and case

management, especially for high-risk patients• care coordination/patient navigation• health promotion and disease

self-management education• transitional care• patient and family support• linkages to community services• psychotherapy/clinical intervention• advance care planning/end of life

assistance

The inclusion of social workers on the teamensures an awareness of the non-medical factorsthat impact patient well-being – namely,environmental and psychosocial needs.Moreover, the social work profession’s ecologicalframework promotes intervention on bothindividual and systemic levels. As a result,patients and caregivers are better supported andmore able to navigate the complexities of thehealth care system with the social worker’sassistance (Golden, 2011). The presence of asocial worker who can address a patient’snon-medical concerns also allows other membersof the interdisciplinary health care team to focuson their specific areas of expertise.

Social work involvement in medicalhome initiativesGeriatric Resources for Assessment andCare of EldersThe GRACE (Geriatric Resources for Assessmentand Care of Elders) medical home projectincludes a nurse practitioner/social worker carecoordination team, which works closely withprimary care physicians and a geriatrician.The program, situated at an urban system ofcommunity clinics affiliated with the IndianaUniversity School of Medicine, enrollslow-income seniors with multiple diagnoses.Data from the project show decreased use of theemergency department and lower hospitalizationrates among seniors receiving the GRACEintervention, compared with those in controlgroups (Counsell, et.al., 2007).

Enhanced Discharge Planning ProgramRush University Medical Center’s Older AdultPrograms and Case Management Departmenthave created the social work-based EnhancedDischarge Planning Program (EDPP). In thisintervention, social workers phone patients andcaregivers after discharge to ensure they arereceiving the services detailed in their dischargeplan. Social workers help patients avoid adverseevents, encourage follow-up with primary careproviders, and connect patients and caregiversto community-based resources (AHA, 2010).Data from the project show statistically significantincreases in seniors’ understanding of theirmedications, decreased stress over managingtheir health care needs, and improvedcommunication with their physicians post-discharge.In addition, older adults schedule and attendtheir follow-up medical appointments more thanpeers not receiving this intervention (Golden,2011)

OU School of Community Medicine—Patient-Centered Medical Home ProjectThe University of Oklahoma School ofCommunity Medicine is shaping its teachingclinics on the medical home model, to providepatients with better access to primary andspecialty care, increased access to medicaladvice, and more efficient and effective treatmentfor chronic conditions. New services to achievethis goal include placing social work staff in carecoordination roles, forming integrated care teamsand improving screening for mental andbehavioral health concerns (PCPCC, 2010).

Commonwealth Care Alliance (CCA)CCA - a Boston-based HMO serving seniors andmedically fragile individuals on Medicaid, usesnurse practitioner-lead teams in 25 community-based medical practices. These teams, whichinclude social workers, are largely responsiblefor the ambulatory care needs of patientsassigned to each practice. Teams provide intakeand assessment, on-going care coordination andin-home assistance with activities of daily living.The physicians on the team focus primarily oninpatient care. CCA’s data are promising. Thenumber of hospital days per year per CCAmember who is dually eligible for Medicare and

Care coordination is central to theshift in orientation away from afocus on episodic acute care to afocus on managing illness andfacilitating preventative self-care,especially for those living withchronic health conditions.

The Duality ofSocial WorkPractice in the VAMedical HomeModel

Two distinct socialwork practice rolescan be found withinthe VA medical homesystem: Mental HealthClinicians and MedicalSocial Workers.

Mental health socialworkers provideindividual, group,and family therapy;drug and alcoholcounseling; andassistance to veteransand their families inadjustment to illnessor disability, andterminal illness.

Medical social workersprovide casemanagement functionssuch as linkingveterans and theirfamily members withresources within theVA system and in theircommunity; assistingveterans with healthcare advancedirectives; andproviding patienteducation (US Deptof Veterans Affairs,2011)

WKF-NL-80811.MedicalHome:TC9990301-LAYOUT-MQ1.qxd 4/12/11 1:06 PM Page 2

Barriers toexpansion of themedical homemodel

• An estimated 65 million

Americans live in officially

designated primary care

shortage areas. Although the

U.S. spends more on specialist

care and has more specialists

per capita than any other

leading industrialized country,

the number of medical students

entering internal and family

medicine residencies is

steadily declining.

• Coordination between primary

care physicians, specialists,

and hospitals is often lacking;

each of these health care

providers is often unaware of

the others’ treatment plans.

• Current fee-for-service and

procedure-based payment

systems that dominate much

of U.S. health care benefit

doctors and specialist

physicians (Project

HOPE, 2010).

• For vulnerable populations,

health promotion and disease

self-management education

are as important as medical

coverage and enrollment.

However, current health policy

allows no reimbursement

mechanism for these services

(Tataw, 2010).

Unique Features of The MedicalHome Model■ Use of Meaningful Performance measuresCurrent medical home demonstration projects –as well as payment models for ACOs - are usingkey performance measures to gauge theireffectiveness. These include:

• Reducing 30 day hospital re-admissions• Delaying permanent nursing home

placement• Reducing avoidable emergency room visits• Increasing access to primary care• Improving patient satisfaction• Decreasing health disparities.

Early evidence suggests that medical homes havethe potential to improve quality and reduce costs.Among vulnerable populations, medical homeprograms are showing improvement in access toprimary care and reductions in avoidableemergency department utilization (Grumbach,2009). Demonstration projects involving socialworkers (see below) are also showing positivetrends on many of these measures.

■ Emphasis on Care Coordination andInterdisciplinary Teams

An essential feature of the patient-centeredmedical home is care coordination. AHRQdefines care coordination as “the deliberateorganization of patient care activities betweentwo or more participants (including the patient)involved in a patient’s care to facilitate theappropriate delivery of health care services”(AHRQ 2010). Care coordination is central tothe shift in orientation away from a focus on

episodic acute care to a focus on managingillness and facilitating preventative self-care,especially for those living with chronic healthconditions (NCCBH, 2009). Within a medicalhome, teams of health care professionals fromdifferent disciplines and practice areas shareresponsibility for managing key components ofpatient care.

The interdisciplinary team approach offersopportunities to improve care and lower costs,especially for patients with depression, physicaldisabilities, and other conditions that haveproven difficult to treat in primary care settings(Commonwealth Fund, 2010). Team-based carealso frees up physician time—as responsibilitiesshift to other staff members—and promotes a workenvironment where all staff can practice at thehighest level their licensure or certification allows.

■ Integration of Behavioral Health intoPrimary Care

Most mental health problems first emerge inprimary care settings; for many vulnerablepopulations, primary care is often the only sourceof mental health treatment. Rates of mental healthproblems are significantly higher for patients withcertain chronic conditions (e.g., diabetes, heartconditions, asthma). Failure to treat both physicaland mental health conditions yields pooreroutcomes and higher costs. (NCCBH, 2009).Although not consistently integrated into allmedical homes, behavioral health—throughco-location or referral protocols—remains animportant component of the medical homemodel (Blount, 2011).

What do social workers offer to themedical home team?Social workers can provide valuable functionson a medical home team, including:• comprehensive assessment and case

management, especially for high-risk patients• care coordination/patient navigation• health promotion and disease

self-management education• transitional care• patient and family support• linkages to community services• psychotherapy/clinical intervention• advance care planning/end of life

assistance

The inclusion of social workers on the teamensures an awareness of the non-medical factorsthat impact patient well-being – namely,environmental and psychosocial needs.Moreover, the social work profession’s ecologicalframework promotes intervention on bothindividual and systemic levels. As a result,patients and caregivers are better supported andmore able to navigate the complexities of thehealth care system with the social worker’sassistance (Golden, 2011). The presence of asocial worker who can address a patient’snon-medical concerns also allows other membersof the interdisciplinary health care team to focuson their specific areas of expertise.

Social work involvement in medicalhome initiativesGeriatric Resources for Assessment andCare of EldersThe GRACE (Geriatric Resources for Assessmentand Care of Elders) medical home projectincludes a nurse practitioner/social worker carecoordination team, which works closely withprimary care physicians and a geriatrician.The program, situated at an urban system ofcommunity clinics affiliated with the IndianaUniversity School of Medicine, enrollslow-income seniors with multiple diagnoses.Data from the project show decreased use of theemergency department and lower hospitalizationrates among seniors receiving the GRACEintervention, compared with those in controlgroups (Counsell, et.al., 2007).

Enhanced Discharge Planning ProgramRush University Medical Center’s Older AdultPrograms and Case Management Departmenthave created the social work-based EnhancedDischarge Planning Program (EDPP). In thisintervention, social workers phone patients andcaregivers after discharge to ensure they arereceiving the services detailed in their dischargeplan. Social workers help patients avoid adverseevents, encourage follow-up with primary careproviders, and connect patients and caregiversto community-based resources (AHA, 2010).Data from the project show statistically significantincreases in seniors’ understanding of theirmedications, decreased stress over managingtheir health care needs, and improvedcommunication with their physicians post-discharge.In addition, older adults schedule and attendtheir follow-up medical appointments more thanpeers not receiving this intervention (Golden,2011)

OU School of Community Medicine—Patient-Centered Medical Home ProjectThe University of Oklahoma School ofCommunity Medicine is shaping its teachingclinics on the medical home model, to providepatients with better access to primary andspecialty care, increased access to medicaladvice, and more efficient and effective treatmentfor chronic conditions. New services to achievethis goal include placing social work staff in carecoordination roles, forming integrated care teamsand improving screening for mental andbehavioral health concerns (PCPCC, 2010).

Commonwealth Care Alliance (CCA)CCA - a Boston-based HMO serving seniors andmedically fragile individuals on Medicaid, usesnurse practitioner-lead teams in 25 community-based medical practices. These teams, whichinclude social workers, are largely responsiblefor the ambulatory care needs of patientsassigned to each practice. Teams provide intakeand assessment, on-going care coordination andin-home assistance with activities of daily living.The physicians on the team focus primarily oninpatient care. CCA’s data are promising. Thenumber of hospital days per year per CCAmember who is dually eligible for Medicare and

Care coordination is central to theshift in orientation away from afocus on episodic acute care to afocus on managing illness andfacilitating preventative self-care,especially for those living withchronic health conditions.

The Duality ofSocial WorkPractice in the VAMedical HomeModel

Two distinct socialwork practice rolescan be found withinthe VA medical homesystem: Mental HealthClinicians and MedicalSocial Workers.

Mental health socialworkers provideindividual, group,and family therapy;drug and alcoholcounseling; andassistance to veteransand their families inadjustment to illnessor disability, andterminal illness.

Medical social workersprovide casemanagement functionssuch as linkingveterans and theirfamily members withresources within theVA system and in theircommunity; assistingveterans with healthcare advancedirectives; andproviding patienteducation (US Deptof Veterans Affairs,2011)

WKF-NL-80811.MedicalHome:TC9990301-LAYOUT-MQ1.qxd 4/12/11 1:06 PM Page 2

PromotingMedicalHomes

Key services

provided by a

patient-centered

medical home

• Preventive screening/health

education

• Acute primary care

• Coordination of diagnostic

services and specialty care

• Management of chronic

health conditions

• Behavioral health care

• End of life care (source:

Commonwealth Fund)

Medicaid is 2.0, compared to 3.6 days perdually eligible patient enrolled in the Medicarefee-for-service program. Also, the percentage ofnursing home–certifiable patients permanentlyplaced in the nursing home per year is 8.5percent, compared with the overall Massachusettsrate of 12 percent (Commonwealth Fund, 2010).

Genesys Health System: Health Navigator SelfManagement Support ModelGenesys, a large, integrated health system inMichigan with 59,000 covered lives, employshealth navigators to work with primary carepatients on chronic disease self management.Navigators have varied backgrounds, includingsocial workers, health educators, dieticians, andnurses. The health system has seen improvementin management of diabetes, chronic pain, anddepression among patients assigned to navigators.

Preventive Health Education and Medical HomeProject for children (PHEMHP)PHEMHP is a program to address both thefinancial and nonfinancial aspects of health careaccess and health status for low-income urbanchildren and families in South Central LosAngeles. Through educational and casemanagement strategies, the program is designedto reduce low levels of health services utilizationand improve preventive health techniques anddisease self-management, with the ultimate goalof attaching each child to a medical home(Tataw, 2010).

IMPACT ModelIMPACT (Improving Mood – Promoting Access toCollaborative Treatment for Late-Life Depression)is a research-based approach to treatingdepression in primary care settings. IMPACTis a collaborative care model, in which theindividual’s primary care physician works witha care manager (usually a nurse, social workeror psychologist), to develop and implement atreatment plan. The care manager and primarycare provider consult with a psychiatrist tochange the treatment plan if the individual’sdepression does not improve. IMPACT Modeldata have shown improvements in depressionmanagement, physical functioning, and painstatus for participants (NCCBH, 2009).

What can Social workers do to PromoteMedical Homes?• Work with NASW state chapters to ensure

social work involvement in state-levelAffordable Care Act medical homedemonstration projects, especially medicalhomes for Medicare/Medicaid enrolleeswith chronic conditions

• Insist that medical home projects includeprevention and treatment of mental illnessand substance use disorders,, along withchronic disease management

• Partner with key stakeholders – stateMedicaid and Medicare programs, providerand payor organizations, patient advocacyorganizations and other groups – onmedical home implementation efforts

• Provide expertise on the unique needs ofvulnerable populations in the developmentand implementation of medical homedemonstration programs

• Engage families and consumers in the workof promoting and advancing the medicalhome concept.

ResourcesThe AHRQ Patient Centered Medical HomeResource Center. This web site provides policymakersand researchers with access to evidence-basedresources about the medical home model.www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483

The Certificate Program in Primary Care BehavioralHealth is a training program for behavioral healthprofessionals seeking to practice in primary caresettings. This training is particularly targeted toprepare behavioral health professionals for the patient centered medical home model. This program is approved for CEs through NASW.http://umassmed.edu/fmch/pcbh/welcome.aspx

National Center for Medical Home Implementation,sponsored by the American Academy of Pediatrics, isa web-based resource center for health professionalsand families interested in medical home informationfor children and adolescents.http://medicalhomeinfo.org/

Patient-Centered Primary Care Collaborative(PCPCC).. The mission of the PCPCC is to strengthenthe primary care delivery system in the US and toadvance the patient centered medical home model.Sponsored by provider groups, large employers andinsurance organizations, the PCPCC plays an active

role as a convener and supporter of medical homedemonstration projects and pilot programs. Currently,27 multi-stakeholder PCPCC projects are underwayin 18 states. The program website includes a host ofmaterials on advancing the medical home model.www.pcpcc.net/

ReferencesAgency for Healthcare Research and Quality.

(2010). The Roles of Patient-Centered MedicalHomes and Accountable Care Organizations inCoordinating Patient Care. AHRQ Publication No. 11-M005-EF. Rockville, MD.

American Hospital Association. (2010). Socialworkers enhance post-discharge for seniors.Hospitals in Pursuit of Excellence. Chicago, IL.

Blount, A. (2011). Integrated Primary Care: TheCentral Piece in the Healthcare Puzzle. Retrievedfrom: www.integratedprimarycare.com/

Commonwealth Fund. (2010, Aug-Sept). In Focus:Using Pharmacists, Social Workers, and Nurses toImprove the Reach and Quality of Primary Care.Quality Matters. Retrieved from: www.commonwealthfund.org/Content/Newsletters/Quality-Matters/2010/August-September-2010/In-Focus.aspx

Counsell SR, Callahan CM & Clark DO, et al.(2007). Geriatric care management forlow-income seniors: A randomized controlled trial.JAMA. 22: 2623-2633.

Golden, RL. (2011, February 16). Coordination,Integration and Collaboration: A Clear Path for

Social Work in Health Care Reform. CongressionalBriefing on the Implications of Health Care Reformfor the Social Work Profession; Washington, DC.

Grumbach, K & Grundy P. (2010) Outcomes ofImplementing Patient Centered Medical HomeInterventions: A Review of the Evidence fromProspective Evaluation Studies in the United States.retrieved from www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf

Project HOPE (2010). Patient-Centered MedicalHomes. Health Affairs. 29:9

National Council for Community BehavioralHealthcare. (2009). Behavioral Health/PrimaryCare: Integration and the Person-CenteredHealthcare Home

National Council for Community BehavioralHealthcare (2011). Partnering with Health Homesand Accountable Care Organizations:Considerations for Mental Health and SubstanceUse Providers Patient-Centered Primary CareCollaborative. Retrieved: www.pcpcc.net/content/ou-school-community-medicine%E2%80%94patient-centered-medical-home-project

Tataw, D., James, F, Bazargan, S. (2009). ThePreventive Health Education and Medical HomeProject: A Predictive and Contextual Model forLow-Income Families. Social Work in PublicHealth. 24:6, 491-510

US Department of Veterans Affairs. (2011). Retrieved:www.va.gov/health/default.asp

WKF-NL-80811.MedicalHome:TC9990301-LAYOUT-MQ1.qxd 4/12/11 1:06 PM Page 3

PromotingMedicalHomes

Key services

provided by a

patient-centered

medical home

• Preventive screening/health

education

• Acute primary care

• Coordination of diagnostic

services and specialty care

• Management of chronic

health conditions

• Behavioral health care

• End of life care (source:

Commonwealth Fund)

Medicaid is 2.0, compared to 3.6 days perdually eligible patient enrolled in the Medicarefee-for-service program. Also, the percentage ofnursing home–certifiable patients permanentlyplaced in the nursing home per year is 8.5percent, compared with the overall Massachusettsrate of 12 percent (Commonwealth Fund, 2010).

Genesys Health System: Health Navigator SelfManagement Support ModelGenesys, a large, integrated health system inMichigan with 59,000 covered lives, employshealth navigators to work with primary carepatients on chronic disease self management.Navigators have varied backgrounds, includingsocial workers, health educators, dieticians, andnurses. The health system has seen improvementin management of diabetes, chronic pain, anddepression among patients assigned to navigators.

Preventive Health Education and Medical HomeProject for children (PHEMHP)PHEMHP is a program to address both thefinancial and nonfinancial aspects of health careaccess and health status for low-income urbanchildren and families in South Central LosAngeles. Through educational and casemanagement strategies, the program is designedto reduce low levels of health services utilizationand improve preventive health techniques anddisease self-management, with the ultimate goalof attaching each child to a medical home(Tataw, 2010).

IMPACT ModelIMPACT (Improving Mood – Promoting Access toCollaborative Treatment for Late-Life Depression)is a research-based approach to treatingdepression in primary care settings. IMPACTis a collaborative care model, in which theindividual’s primary care physician works witha care manager (usually a nurse, social workeror psychologist), to develop and implement atreatment plan. The care manager and primarycare provider consult with a psychiatrist tochange the treatment plan if the individual’sdepression does not improve. IMPACT Modeldata have shown improvements in depressionmanagement, physical functioning, and painstatus for participants (NCCBH, 2009).

What can Social workers do to PromoteMedical Homes?• Work with NASW state chapters to ensure

social work involvement in state-levelAffordable Care Act medical homedemonstration projects, especially medicalhomes for Medicare/Medicaid enrolleeswith chronic conditions

• Insist that medical home projects includeprevention and treatment of mental illnessand substance use disorders,, along withchronic disease management

• Partner with key stakeholders – stateMedicaid and Medicare programs, providerand payor organizations, patient advocacyorganizations and other groups – onmedical home implementation efforts

• Provide expertise on the unique needs ofvulnerable populations in the developmentand implementation of medical homedemonstration programs

• Engage families and consumers in the workof promoting and advancing the medicalhome concept.

ResourcesThe AHRQ Patient Centered Medical HomeResource Center. This web site provides policymakersand researchers with access to evidence-basedresources about the medical home model.www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483

The Certificate Program in Primary Care BehavioralHealth is a training program for behavioral healthprofessionals seeking to practice in primary caresettings. This training is particularly targeted toprepare behavioral health professionals for the patient centered medical home model. This program is approved for CEs through NASW.http://umassmed.edu/fmch/pcbh/welcome.aspx

National Center for Medical Home Implementation,sponsored by the American Academy of Pediatrics, isa web-based resource center for health professionalsand families interested in medical home informationfor children and adolescents.http://medicalhomeinfo.org/

Patient-Centered Primary Care Collaborative(PCPCC).. The mission of the PCPCC is to strengthenthe primary care delivery system in the US and toadvance the patient centered medical home model.Sponsored by provider groups, large employers andinsurance organizations, the PCPCC plays an active

role as a convener and supporter of medical homedemonstration projects and pilot programs. Currently,27 multi-stakeholder PCPCC projects are underwayin 18 states. The program website includes a host ofmaterials on advancing the medical home model.www.pcpcc.net/

ReferencesAgency for Healthcare Research and Quality.

(2010). The Roles of Patient-Centered MedicalHomes and Accountable Care Organizations inCoordinating Patient Care. AHRQ Publication No. 11-M005-EF. Rockville, MD.

American Hospital Association. (2010). Socialworkers enhance post-discharge for seniors.Hospitals in Pursuit of Excellence. Chicago, IL.

Blount, A. (2011). Integrated Primary Care: TheCentral Piece in the Healthcare Puzzle. Retrievedfrom: www.integratedprimarycare.com/

Commonwealth Fund. (2010, Aug-Sept). In Focus:Using Pharmacists, Social Workers, and Nurses toImprove the Reach and Quality of Primary Care.Quality Matters. Retrieved from: www.commonwealthfund.org/Content/Newsletters/Quality-Matters/2010/August-September-2010/In-Focus.aspx

Counsell SR, Callahan CM & Clark DO, et al.(2007). Geriatric care management forlow-income seniors: A randomized controlled trial.JAMA. 22: 2623-2633.

Golden, RL. (2011, February 16). Coordination,Integration and Collaboration: A Clear Path for

Social Work in Health Care Reform. CongressionalBriefing on the Implications of Health Care Reformfor the Social Work Profession; Washington, DC.

Grumbach, K & Grundy P. (2010) Outcomes ofImplementing Patient Centered Medical HomeInterventions: A Review of the Evidence fromProspective Evaluation Studies in the United States.retrieved from www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf

Project HOPE (2010). Patient-Centered MedicalHomes. Health Affairs. 29:9

National Council for Community BehavioralHealthcare. (2009). Behavioral Health/PrimaryCare: Integration and the Person-CenteredHealthcare Home

National Council for Community BehavioralHealthcare (2011). Partnering with Health Homesand Accountable Care Organizations:Considerations for Mental Health and SubstanceUse Providers Patient-Centered Primary CareCollaborative. Retrieved: www.pcpcc.net/content/ou-school-community-medicine%E2%80%94patient-centered-medical-home-project

Tataw, D., James, F, Bazargan, S. (2009). ThePreventive Health Education and Medical HomeProject: A Predictive and Contextual Model forLow-Income Families. Social Work in PublicHealth. 24:6, 491-510

US Department of Veterans Affairs. (2011). Retrieved:www.va.gov/health/default.asp

WKF-NL-80811.MedicalHome:TC9990301-LAYOUT-MQ1.qxd 4/12/11 1:06 PM Page 3

PracticePerspectives

The Medical Home Model:What Is It And How Do Social Workers Fit In?

10IS S U E

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BackgroundThe “medical home” concept dates to the late1960s and has, until recently, been confinedlargely to the pediatric community. However,in the health reform era, the concept is beingembraced as a model of health care deliverythat is comprehensive and cost efficient,particularly for people with complex healthconditions. Medical home programs aregrowing rapidly, fueled by interest from boththe public and private sectors. The hallmark ofthe medical home is integrated, multi-disciplinarycare that meets a patient’s physical andbehavioral health needs. The AffordableCare Act of 2010 advances a systems-levelmanifestation of the medical home—the“accountable care organization” (ACO)—a health care delivery model intended topromote shared accountability for improvingpatient care and controlling costs for adefined population. Social workers arewell positioned to participate in these healthdelivery models – and have demonstratedtheir value in many of the medical homedemonstrations projects currently underwaythroughout the nation.

What is a medical home?At its most fundamental, a medical homesuggests an on-going relationship between anindividual and his or her primary care team.A medical home provides care that ispatient-centered, team-based, comprehensiveand coordinated. The Agency for HealthcareResearch and Quality (AHRQ) suggests that amedical home is not just a place, but a modelfor organizing primary care that meets thelarge majority of a patient’s physical andmental health care needs, including preventionand wellness, acute and chronic care (AHRQ,2010). A medical home provides carethrough an interdisciplinary team, composedof physicians, advanced practice nurses,physician assistants, nurses, social workers,and pharmacists. Some medical homes willemploy diverse teams directly; others will buildvirtual teams, linking themselves and theirpatients to providers and services in theircommunities. Medical homes vary in size fromsmall (physician practices) to mid-size (safetynet providers such federally qualified healthclinics and free clinics) to large scale (e.g.,non-profit health systems and the Departmentof Veterans Affairs).

Stacy Collins, MSW

Senior Prac t i ce Assoc ia te

sco l l ins@naswdc.org

ProfessionalDevelopment

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Practice Perspectives Issue 10 April 2011

The NationalAssociation ofSocial Workers

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Workforce Studies & Reports available atWorkforce.socialworkers.org/studies/other.asp• Criminal Justice Social Work: Adapting to New Challenges• Child Welfare Social Workers’ Attitudes Toward Mobile

Technology Tools: Is There a Generation Gap?• 2009 Compensation & Benefits Study: Summary of Key

Compensation Findings

Social Work Practice Updates available atSocialWorkers.org/practice/default.asp• 2010 Medicare Changes for Clinical Social Workers• A Shift in Approach: Addressing Bullying in Schools• Biopsychosocial Challenges Related to Transitions of Care• Clinical Social Workers Be Aware: The ICD–10–CM is Coming• Delivering Culturally Appropriate Care for Older Adults• Enrolling In Medicare as a Clinical Social Work Provider• From Poverty to Child Welfare Involvement: The Critical Role

of Housing in Family Stability• MDS 3.0: Implications for Social Workers In Nursing Homes

and Community-Based Settings

• Medicare-Mandated Reportable Changes for Clinical SocialWorkers in Solo or Group Practice

• Meeting the Challenge of Supervision in School Social Work• Meeting the Needs of Immigrant Children and Youth In Child

Welfare• Part II: Advocating for Change in Home Health Care• Pharmaceutical Industry Prescription Assistance Programs:

Benefits and Challenges• Results of Request for Compelling Evidence to Increase

Psychotherapy CPT Codes• Social Work and Transitions of Care• Social Workers: A Bridge to Language Access Services• The Childhood Obesity Epidemic: The Social Work Response• The Economic Downturn: Implications for School Social Work• Trends in Medication Adherence• When A Clinical Social Worker in Solo or Group Practice Dies• Women and Domestic Violence: Implications for Social Work

Intervention• Youth Aging Out of Foster Care: Supporting Their Transition

into Adulthood

Center for Workforce Studies & Social Work Practice Recent Publications

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