Primary Care Medical Home: Implications for Addiction Care

United States

Meeting Organizers: Sarah Duffy, Ph.D.Richard Denisco, M.D., M.P.H.

Meeting Purpose and Intent:

The purpose of this one-day meeting was to develop a research agenda to generate science that improves the ability of primary care, or patient-centered, medical homes (PCMH) to meet the needs of patients with or at risk of addictive disorders and misuse of illicit drugs and prescribed medications. This meeting detailed the current situation in the primary medical care system, and the ways that the PCMH may be able to at least partially correct these problems. A research agenda was outlined that considered the drug abuse interventions and service strategies that might be appropriate in the PCMH. Research questions that would facilitate the development and maintenance of linkages between specialty providers and the PCMH were discussed, as were questions related to optimal financing and payment models to accomplish these goals.

Meeting Outcome, Emerging Themes:

Participants presented information concerning the PCMH and addiction treatment:

• Participants presented information on the current state of the primary medical care system, including reimbursement disparities, lagging workforce moral, and continual decreasing numbers of medical students entering the primary medical care specialties and the inadequacy of these trainees to provide for future health care estimates
• Specifically: The first session reviewed the PCMH concept in theory and described how it is being implemented in practice to provide all meeting participants with a common understanding of the concept and the realities of its implementation. The second session was a discussion of some of the unique characteristics of addiction treatment and how they affect its integration into a primary care, and specifically the primary care medical home. The goal is to acquaint participants who have or may be interested in studying PCMHs with addiction issues to help them better generate research that can promote its inclusion. The third session involved all participants and was devoted to developing the research agenda for health services research on addiction in the medical home including topics such as effectiveness and comparative effectiveness, management and organizational studies, quality measurement and outcomes, and economics studies.
• A number of major research areas were developed in the third session, these include:
  • Specific interventions required for screening and intervention with addiction and other behavioral health issues Learning from practice models that are in pilot programs was encouraged.
  • Organizational and management changes to establish addiction as one of the key chronic diseases to address in the primary care medical home.
  • Research to determine which financing structures and incentives will be best for promoting the efficient, effective management of addiction in the PCMH, and what effect will various funding mechanisms have on the implementation of addiction in the PCMH.
  • Research into ways to reduce stigma among physicians and staff and ways to comply with the confidentiality laws but not hinder patient care and communication between providers.
  • What performance measures should be added to the existing measures incorporated into the PCMH.
  • Organizational and management issues require research to determine optimal ways to transition from current system to a medical home system. And would transition be best accomplished incrementally or in totality.
  • What are the outcome measures that are optimal to determine success of the medical home, cost-effectiveness, health outcomes, patient and/or medical team acceptance and perceived value. Should outcomes or process measures be used, or is a mixture of both optimal. Prior problems with using isolated outcome measures, i.e. HbA1C were noted, and a need to avoid this approach was noted.
  • Research to use the electronic health record and other impending technology to facilitate advances in primary care medicine either as it is practiced, or in the PCMH was considered central to the concept. However technology alone does not create or define the medical home, and over-reliance on it was cautioned.

Future Plans:

Participants were encouraged to consider various research methods from RCTs to natural experiments to address these questions, and to submit proposals as grant applications. It was noted that NIDA has a mechanism that supports implementation research in community-based practices. Building System Capacity for Implementing Evidence-Based Practices in Substance Abuse Treatment and Prevention (R34) (http://grants.nih.gov/grants/guide/pa-files/PA-09-105.html) and this mechanism is designed to move evidence-based approaches into practice. It was also noted that the CTSA network is comprised of centers throughout the United States. These centers would be ideal platforms for some of the proposed research because they integrate general medical care with organization from one central coordinating group. Drug Abuse Epidemiology and Services Research in Cooperation with the Clinical and Translational Science Awards Consortium (R01) PAS-09-001 http://grants.nih.gov/grants/guide/pa-files/PAS-09-001.html