Nearly half of all Americans have at least one chronic illness, and for people over the age of 65, the proportion is 85 percent. Providing care for people with chronic illnesses represents a vast share of national healthcare expenditures, so effectively managing the care of these patients is critical for controlling spending.
According to a study published in Health Affairs, between 2006 and 2013 there has been a relatively large industry-wide increase in the use of evidence-based care management processes associated with patient-centered medical homes for patients with chronic conditions including asthma, congestive heart failure, depression and diabetes. However, large medical practices used fewer than half of the recommended processes.
Researchers used three national surveys of physician practices conducted between 2007 and 2013 to assess the extent to which practices have increased their use of these evidenced-based processes.
Six practice size categories were included in the study for comparison to earlier studies. Four of these were categorized as small- and medium-sized practices, with one to two, three to seven, eight to 12 or 13 to 19 physicians. Large practices are those with 20 to 99 physicians and those with 100 or more. Researchers also defined 18 components of PCMH. These include primary care teams, care coordination or integration, EMR for progress notes, electronic access to ED visits and hospital discharge, electronic coordination with pharmacy and others.
For small- and medium-sized practices, PCMH use increased from 21 to 29.4 percent between 2006 and 2013. For large practices, use of these practices increased from 32.6 percent to 46.7 percent.
Large practices increased use of nine of these components, while small- and medium-sized practices significantly increased their use of eight, according to the study. Both groups showed the most improvement in five PCMH processes, each related to the use of EMRs. These include using the EMR for progress notes, coordination with the pharmacy, generating measures of care quality, clinical decision support and giving patients online access to their records.
Small- and medium-sized practices, but not large practices, increased the use of nurse care managers for chronic conditions, the use of non-physician staff for patient education, the use of patient reminders for preventive care and follow-up for the conditions and physician communication with patients by email.
Two areas in which increases were higher for large practices than for small- and medium-sized practices include participation in quality improvement collaboratives and the use of plan-do-study-act cycles. According to the study, all three sizes reported declines in incorporating patient feedback into the practice.
Small- and medium-sized practices declined in two areas that large practices did not, including having electronic access to emergency departments and hospital discharge information and in providing group visits for patients.