Gary Oftedahl: Could I live in a "health care home?"

In the past several weeks, I’ve had occasion to experience two events which have elevated my angst regarding much of the hype around the PCMH (patient-centered medical home) model.  Understand, I conceptually get it.  It’s totally in line with my philosophies, principles, and beliefs.  A team-based approach, with leveling of the hierarchy in which I’ve practiced, the attention to evidence-based medicine, the patient-centered focus all resonate.  Indeed, my hopes for some sanity to the payment model are often enhanced by the evolving whole patient approach envisioned in the PCMH model.

But every once in a while, I have to stop and consider a basic question.  We’re talking about the need to engage and include our “patients” in the successful creation of this model.  Metaphorically, while there is a blueprint for the model (although how complete that blueprint is will foster multiple debates), will we find those who will furnish and live in the house being designed?  In fact, the angst I have in the beginning is whether or not I could live in this home.  Perhaps you can assuage my fears, assault my assumptions, or quiet my fears.  Please!!

I recently was presenting at a wonderful PCMH initiative meeting being held in Colorado.  Touted as an expert, I spoke on the need to integrate mental/behavioral health into the PCMH model, the challenges of engaging people in change, and lastly, identifying patients’ needs and readiness to become involved.  As I progressed through my Powerpoint slides regarding engaging patients, I spontaneously asked the audience a basic question–since you’re developing a patient-centered model, and working as a team, how many of you in the room are the patient’s voice?  Not a single hand rose into the air. As I glibly and cleverly responded to them my concerns about that missing participation, a flame of discomfort was fanned.  My previous concerns about whether or not we really understand what our patients want  began to activate previously hibernating neurons.

This unsettling synaptical occurrence was expanded shortly thereafter as I discussed the concept of patient activation.  I’ve been intrigued by the work of Judy Hibbard, her development of the Patient Activation Measure, and it’s implications in advancing our understanding of how we might meet patients where they were.

But as I talked with the group about her four levels of activation, more of those irritating synaptical firings started occurring.  The lowest level of activation is a belief that the patient role is important.  In other words, do I even think what I do makes a difference?  The second level involves feeling I have the knowledge to make the behavior changes necessary.  These are necessary but certainly not sufficient requirements to becoming an active participant.  Level 3 involves being able to implement the behavior changes needed and sustain them with support.  Level 4 reflects a person who can sustain those behaviors when confronted with stress.

As I spoke with the crowd, and addressed those concepts, I realized that while conceptually appealing, and rhetorically convincing, we may be kidding ourselves. For, as I spoke from my role as an “expert” those intrusive neuronal firings began attacking my “expertise.”  I suddenly started spontaneously talking with the group about the irony I saw of asking our patients to do what we ourselves can’t and don’t do.  Let me explain this from my perspective–after all, all change is personal, no matter how intellectually appealing the concept sounds.

I’m a smart, educated, committed individual.  I also have the luxury of having resources available to support in many ways the activities which would allow me to be a level 4 person.  But as I spoke with the group, I felt fraudulent in some way.  As I espoused the need to have patients engaged at a level 3 or level 4, it struck me that it was ironic, and perhaps hypocritical that I would ask my patients to do what I’m not capable or able to do.

I’m basically healthy, no real risk factors.  I should exercise regularly, eat correctly, get the rest I need, take a baby aspirin every day.  Pretty basic, right?  Yet because my job has become bigger, more complex, and time consuming, I find myself excusing the exercise  (just don’t have the time, too tired, maybe tomorrow).  Then because it’s convenient, I start eating in a way that my patients would suggests is inconsistent with my message.

So, back to those irritating neuronal activations.  If I, as an educated, committed aging person, with adequate resources and few excuses can’t move to a level 3 or 4, or sustain it, how in the world do I expect my patients to do this.  Burdened with two jobs, trying to live from day to day, worrying about the potential loss of a job, dealing with multiple demands coming from every direction—are we kidding ourselves?  We’re developing a model which is dependent on an actively engaged, involved participant, able to fit significant behavior changes and lifestyle alterations into a life which is already overfilled with fears, deficiencies, and demands.

In fact, if I was offered the chance to live in the “health care home” or PCMH model, would I meet the criteria to be a model citizen?  There’s much more to say, and perhaps you have a different take.  Perhaps I’m just a laggard, lazy, unfocused, uncommitted.  Or perhaps, in the traditional medical vernacular, I’m just “non-compliant.”

Health care reform is in a state of chaos, the opportunities are many, but all seem to involve an involvement and participation by the public never seen before.  If the PCMH (health care home) is an element of that reform, do we have residents who will be able to meet the “mortgage” requirements?   I’m embarrassed to say that I’m not sure my “credit rating” would meet those we’re looking for from those we serve.

I’d appreciate your thoughts, does anyone else have these concerns?  If so, please share your solutions with me, so I can reduce those increasingly persistent synaptical actions which are keeping me awake at night.  Even worse, as if my Colorado epiphany wasn’t enough, I visited my financial planner last week.  But more about that and it’s relevance next time.  For now, help me with my need to improve my “credit rating.”

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