One term commonly encountered in PC today is the PCMH (also referred to as the “patient-centered healthcare home,” “medical home,” or “healthcare home”). The PCMH lists a number of aspirations for how to structure and deliver PC. In 2007, the major PC associations joined together to create and publish the Joint Principles of the Patient Centered Medical Home. Since then, the model has evolved to consist of the following five components (Agency for Healthcare Research and Quality, 2014):

In 2011, the National Committee for Quality Assurance (NCQA), the primary agency responsible for certifying, or “recognizing,” an organization as a PCMH, detailed PCMH program standards. Such recognition is voluntary. The six standards include: (1) patient-centered access to care, (2) team-based care, (3) population health management, (4) care management and support, (5) tracking and coordination of care (e.g., for referrals), and (6) measuring and improving performance. The NCQA will help clinics prepare for recognition, including ensuring that electronic health record (EHR) systems, advanced registries, population health management tools, and other technology-related aspects of care align with PCMH standards (AHRQ, 2014).

Many studies conducted in a variety of settings, and even different countries, have shown that the PCMH can improve quality, lower costs, reduce errors, and improve patient satisfaction (e.g., see Reid et al., 2010; Rosenthal, 2008). At the same time, research has also questioned the results of the PCMH. It is often applied very differently from one system to another, and results have sometimes been less than expected (Hoff, Weller & DePuccio, 2012; Peikes, Zutshi, Genevro, Parchman & Meyers, 2012). One important point about the PCMH is that, as noted by Freeman (2011), behavioral health providers have not typically been considered members of the PCMH team. The joint principles merely recommend that a physician lead the team; other PCMH policy papers rarely discuss behavioral health, other than those written by behavioral health professionals themselves. Seemingly, when conceptualizing the PCMH team, most think only of the usual staff, such as the physician, RN, lab technician, and MA. Freeman concludes that, “Behaviorists…are considered external to the Healthcare Home by the chief architects of the concept.” The American Psychological Association (2009) has also noted this and has lobbied for change. The 2014 revision of the PCMH standards do promote enhanced care for behavioral issues, but unfortunately they still do not require a behavioral health presence be integrated into the team.

This omission is unfortunate, given that so much of what the PCMH is intended to help with involves conditions with a behavioral component. One might imagine that some, if not all, of the goals of the PCMH would be much more easily met if every PCMH team had strong behavioral health support. Indeed, data from a Blue Cross/Blue Shield analysis of care outcomes in the behaviorally enhanced PCMH of Cherokee Health Systems, in Tennessee, found exactly that (Freeman, 2011). Compared to patients of other PC systems in the same region, Cherokee patients used emergency rooms, medical specialists, and hospital care significantly less; and the overall cost of Cherokee’s patients was significantly and substantially lower. Cherokee was an early adopter of the PCBH model, and the only difference between Cherokee and the other PC systems was the presence of a BHC on Cherokee’s PCMH teams (Freeman, 2011).

Thus, while the PCMH holds promise as a model for improving PC, it would likely benefit from a greater emphasis on the role of behavioral health in PC. Given the behavioral nature of so many of the problems seen in PC, the PCMH team that adds a BHC should be well on its way toward meeting the ideals of the PCMH approach. We turn our attention now to other terms closely associated with PCMH, which a BHC will surely encounter.

In their seminal 2008 paper, Berwick and colleagues suggested a strategy for achieving the Triple Aim, and most healthcare reform efforts have lined up with the strategy suggested. Note that a key element of the Triple Aim strategy is redesigning PC to be consistent with the goals of the PCMH. Stiefel and Nolan (2012) offer a guide to Triple Aim measurements and we will provide more on this in Chapter 8 as a part of a discussion on measurement and PCBH program evaluation.

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act, commonly called the Affordable Care Act (ACA), or colloquially termed “Obamacare.” It mandates a series of comprehensive health insurance reforms so vast that even a separate book on the topic would fail to do it justice. For the purposes of this book, we will highlight several key aspects of the new law relevant to the PCBH model.

First, the ACA aims to assure that all Americans have access to affordable health insurance options, including millions of people who were previously uninsured. People who have been excluded from healthcare insurability due to preexisting conditions, young adults who previously lost insurance when turning 18, and those people who simply could not afford it, all may now have access to insured health care. Second, the law emphasizes the importance of PC and attempts to strengthen it in various ways, including incentivizing medical students to work in PC, particularly in medically underserved areas. Third, the law aims to move health care away from the episodic, fee-for-service model of care delivery and toward a preventive, coordinated model. For example, it mandates that Medicare pay for a yearly wellness visit, creates a 15 billion dollar fund for prevention and public health, and encourages PCPs to join together in “Accountable Care Organizations” to improve care coordination, which we discuss later in this chapter.

All of these initiatives are likely to produce enormous changes in how PC is organized, provided, and paid for in the years to come. For a BHC, at the time of writing this book, there are two significant ramifications. First, many PC clinics will see an influx of new patients, and many of these new patients will have been without recent health care. This will make the already stressed PC system even more so. It is estimated that the country will need about 52,000 additional PCPs by 2025 to meet the new demand, and that, of course, will take some time to happen (Petterson et al., 2012). Second, there will be greater competition for patients among healthcare organizations, as the newly insured sort through care options. This is especially likely to affect community health centers, which previously were the only viable option for uninsured patients.

These ramifications will create new challenges in PC, but they will also create new opportunities, especially for an energetic BHC. As discussed throughout this book, the goal of the PCBH model is to help PCPs be more efficient and effective, meaning a strong BHC service could help ease the strain of the PCP shortage. The influx of new patients, many of whom will have chronic problems, means plenty of opportunities should exist for a BHC to help his new PCP colleagues. A recent RAND report suggested that use of the PCMH could cut the expected shortage of PCPs in half (Auerbach et al., 2013), and that is, of course, without considering the additional help that a BHC could provide to the PCMH. In addition, the new competition for patients means clinics will need to be improving and meeting the needs of their population more than ever. For many clinics, especially community health centers, this means building the best team possible to meet the medical, social, and behavioral needs of patients, and that translates to great potential for a BHC service. If nothing else, the emphasis that the ACA puts on PC means the job market for BHCs should be strong and the opportunities plentiful for doing meaningful work. Thus, we encourage BHCs to embrace the challenges of the new care environment. As the saying goes, “In chaos there is also opportunity.”

Elliott Fisher introduced the term Accountable Care Organization (ACO) in 2006, at a meeting of the Medicare Payment Advisory Commission. It was included in the federal Patient Protection and Affordable Care Act and now there are ACOs in every state. While ACOs may vary, all share the following three characteristics.

In order for ACOs to succeed in their mission to foster excellent care while simultaneously saving money, their sponsors will need to create incentives for hospitals, physicians, post-acute care facilities, and ACO staff to work together to strengthen linkage and coordination of care delivery. The devil will surely be in the details on this very good idea, and BHCs will likely to be in a position to play a pivotal role.

A Coordinated Care Organization (CCO) is a network of different types of healthcare providers (often medical, addiction, MH, and sometimes dental) who have agreed to work together to better serve the healthcare needs of their community. If you think of the PCMH as a patient’s medical home, you can think of the ACO or CCO as the patient’s medical neighborhood. In the state of Oregon, 15 CCOs are providing both prevention and chronic care management services to the state’s Medicaid recipients. The state’s goal is meeting key quality measurements for improved health for clients served while reducing spending growth by 2 percentage points per member over the next 2 years.

In this book, the term PCP includes physicians as well as nurse practitioners (ARNPs), physician assistants (PAs), naturopathic physicians, and any other providers who independently oversee all aspects of a patient’s PC. In this definition, nutritionists, BHCs, acupuncturists, and some others may be “providers,” in the sense that they provide care, but they are not PCPs because they do not govern all aspects of care.

The PCP is a generalist who provides care for any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient), regardless of the patient’s age, the problem origin (biological, behavioral, or social), or the organ system involved. The PCP provides the first point of contact for such care and takes continuing responsibility for it, consulting with or referring to other health professionals as needed. The majority of a PCP’s practice is devoted to a defined population of patients (her “panel”), who may remain under her care throughout the entire life span. The PCP is also an advocate for the patient in coordinating use of the entire healthcare system to benefit the patient.