Can Urgent Care Play a Role in the Medical Home Model?

Written by on October 1, 2014 in Features - No comments

Introduction:

Recently featured in medical news are the growth of urgent care (UC) clinics and the concept of the medical home. Both are becoming a part of mainstream medicine. Urgent care clinics can now be found in almost every mid- or large-sized community, and they are likely here to stay. They are treating many patients who in the past could only be seen in traditional medical clinics or the emergency department (ED). Many of these traditional medical clinics are adapting to the new ideal of the medical home, whose goal is to provide comprehensive and centered care to the patient and family. At first glance these two entities seem to be at odds, but with the right models and motivation, urgent care clinics can indeed play a role in the medical home model.

HomeMedicineWEBThe Medical Home:

The American Academy of Pediatrics (AAP) introduced the concept of the medical home in 1967 to create a center for a child’s medical records, initially focusing on children with special needs. More recently, the medical home has expanded to become a home base for the care-both medical and non-medical-for all children and adults.  The Health Resources and Services Administration defines the medical home as “a cultivated partnership between the patient, family, and primary care provider in cooperation with specialists and support from the community”. According to the AAP, some of the key characteristics of the medical home are that the care provided is “accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective”. Several organizations, including the AAP, have collaborated to form the Joint Principles of the Patient Centered Medical Home. This organization has defined seven key principles for a medical home. These include:

  • Personal Physician-to be the first, ongoing, and coordinating care provider
  • Physician directed-the physician leads the team
  • Whole person orientation-includes acute, chronic, preventative, and end-of- life care as well as mental and behavioral health, dental health, and other needs
  • Care is coordinated and/or integrated-this includes the primary physician as well as subspecialty care, hospitals, home health agencies, nursing homes, as well as community-based services. Information must be able to be accessed and shared among these groups.
  • Quality and safety are vital-this incorporates evidence-based medicine, clinical decision-support tools, quality improvement activities, information technology, accountability, and patient-centered care
  • Enhanced access to care-through expanded hours, open scheduling, and patient portals which also may allow online scheduling
  • Payment-which recognizes and reflects the value of additional services provided

In addition, an effective medical home should incorporate several other objectives such as: ease of referrals, a high level of communication of the primary provider with other physicians and programs, adequate time spent with the family, cultural sensitivity, and interpreter service availability.

In short, the medical home provides comprehensive care in partnership with a patient and family to meet all of the medical and non-medical needs of the patient.

Urgent Care:

Urgent Care clinics are big business, and they are growing. Several recent articles demonstrate the recent rapid growth in urgent care clinics and estimate that there are currently from 5000 to 9,000 clinics that may be classified as urgent care in the United States, with approximately 50-100 new clinics opening per year.

Essentially, urgent care clinics fall somewhere between primary care and an emergency department. They focus on acute care, though they do not aim to treat the severity of conditions seen in an ED. Most urgent care clinics share the following characteristics:

  • Accept walk-in patients
  • Are open extended hours, usually including evenings, weekends, and holidays
  • Are staffed and led by at least one physician
  • Have on-site diagnostics such as radiology and laboratory services
  • Treat a variety of acute illnesses and injuries, including musculoskeletal injuries and lacerations, and have the ability to perform minor procedures
  • Contain multiple exam rooms

Urgent care clinics provide several advantages to the traditional ED- namely cost, convenience, and time/efficiency. With higher copays and deductibles, this cost difference matters to patients as well as to insurers, employers, and taxpayers.

There are several different business models of urgent care clinics. These include clinics owned by physicians, hospitals, or health-plans, as well as non-physician individual or corporation-owned centers, and franchises. Initially heavily physician-owned, there is a shift towards more franchise and other non-physician ownership.

Can urgent care clinics play a role in the medical home model, and if so, what are the key characteristics of those that do?

The most important concept is that urgent care is not, and should not attempt to replace, the medical home; rather, it should complement it.

Urgent care clinics are growing; people are now treating health care similar to the rest of their lives, where convenience is key. Studies show the primary motivations for going to an UC clinic are convenience, timely care, and affordability. In addition, a nationwide shortage of primary care physicians and overcrowded emergency departments contribute to this growth.

There are many benefits of urgent care and many appropriate uses. When an injury occurs or an illness flares after office hours, urgent care is a great option for care. However, an increase in the inappropriate use of urgent care for non-urgent concerns is a problem that has significant economic and healthcare consequences. Using urgent care in place of primary care opposes the concept of the medical home. The medical home stresses continuity and the role of the primary care physician; when patients bypass the primary care physician and choose urgent care instead, the many benefits of the medical home are lost. Patients who primarily utilize resources such as urgent care may not receive preventive care services or adequate care for their chronic medical conditions.

Although they may have access to patient records, urgent care providers don’t usually know the patient’s full medical history. Urgent care may treat patients with an acute exacerbation of a chronic condition, but it is not the appropriate place to manage the conditions themselves or to make significant long-term medication or treatment changes. Urgent care usually has limited imaging and laboratory services and does not have close relationships with specialists. Finally, although urgent care providers may address prevention, behavioral, safety, mental health, dental, and other “whole person” issues, they are not equipped to provide the level of service needed for quality care.

When used appropriately; however, urgent care can indeed play a role in the medical home model, and when an urgent care clinic is developed with the medical home in mind, it can be an effective one. There are several key concepts that must be included to make this possible.  These include several key characteristics and principles of a medical home as noted above, as well as several others:

Accessible:

This is one of the key advantages of urgent care. With clinics in the community away from the hassles of navigating a large medical center; evening, weekend, and holiday hours; and immediate walk-in services; urgent care provides many convenient features. Lower copays and fees than emergency departments also provide accessibility to patients with economic limitations. Along with this, patients in certain geographic areas have limited access to primary care providers due to a shortage, and the increased number of people seeking care as insurance coverage is expanded under the Affordable Care Act will only increase this problem.

Collaboration/cooperation/coordination:

Probably the most important concept to align urgent care with the medical home is collaboration of the clinic with the primary care provider (PCP) and community organizations. Two-way communication between the urgent care clinic and primary care provider is optimal. This includes phone calls, letters, faxes, and electronic records from the urgent care clinic to inform the PCP of the details of the patient’s visit and follow-up recommendations. Occasionally, a PCP may refer a patient to urgent care and even provide information to facilitate care for a more ill or complicated patient. In addition, the UC provider contacts the ED or hospital before transferring a patient and may even contact a specialist to discuss the care of a patient. A shared electronic health record (EHR) can help provide accurate, thorough, and timely information. In addition to sharing information, the UC provider should attempt to be consistent with the treatment plans in place by the PCP when available and appropriate and refer the patient back to the PCP for further care. If the provider has alternative ideas for care, then contacting the PCP with these or including them in discharge instructions can be helpful. Finally, to be even more successful, an urgent care clinic could work with the local hospital or other community health resources to align their scope of care, treatment guidelines, quality and safety controls and improvement strategies, and triage and transfer protocols with that of the hospital or other organizations.

Of course, this collaboration only works if the patient actually has a primary care provider. In pediatrics, most patients are seen by a pediatrician or family physician regularly due to routine check-ups and immunizations, so this should be more easily attainable. Unfortunately, many adults don’t have a regular care provider, especially younger adults who often don’t see the need or those without insurance coverage. It is especially important for older adults or those with chronic medical problems to have a medical home to manage their health in a more efficient and thorough manner.

Quality and safety of care and quality and safety improvements:

Urgent care clinics should have in place the same level of quality and safety measures and accountability as other medical practices. UC providers should practice evidence-based medicine. To facilitate quality and safety, electronic health records should be utilized, ideally those that allow sharing of information between centers, contain clinical decision-support tools, and allow capture of data to measure outcomes. Finally, protocols for triage, transfers, and managing emergent situations should be in place and evaluated and practiced at regular intervals.

Culturally effective/Community:

Urgent care clinics are often located in the community neighborhoods and employ staff that lives in the same neighborhoods. This can aid in the cultural sensitivity and effectiveness of the clinic along with decreased language barriers. Interpreter services are essential when staff is not fluent.

Physician led:

As noted above, an urgent care clinic should be led and staffed by at least one physician. Many clinics may have nurse practitioners or physician assistants working with physicians, but this is similar to most medical practices and even emergency departments. While a good nurse practitioner or physician assistant can be invaluable, a physician is able to independently recognize and manage more ill or complicated patients.

Cost:

This is not the same concept as payment, but deserves mention. A medical home is valuable in many ways, and one of them is reduction of the cost of care. A coordinated medical home attempts to keep costs low by reducing hospital admissions, inappropriate emergency department use, and duplication of services. Most urgent care fees are slightly higher, but similar, to those of a primary care provider, and they are usually much less those of an ED for similar conditions. A concern, however, would be unnecessary visits to urgent care when a phone call to the primary care provider for advice, refills, etc., could suffice. Another concern is the possibility of duplication of services from an urgent care if they do not have access to results of diagnostic testing completed or the plan of care in place by the primary provider or other sources. In addition, inherent in their nature, ED and UC clinics tend to rely more heavily on diagnostic tests than primary care providers, which can add to higher costs.

Scope of care:

Urgent care clinics should define the scope of illnesses and injuries they manage. They should not exhaustively diagnose or treat chronic illnesses more than the acute flare, unless the patient is in need of care that is not being provided by a primary physician. In general, preventive medicine is not a focus of urgent care. When treating patients who are lacking in preventive care or management of chronic conditions, UC providers should encourage the establishment and consistent use of a primary care provider.

Type/model of urgent care matters:

Considering the different models of urgent care and the above issues, some are better able to fit into the medical home model. Because of their integration and alignment with health systems and insurance companies, hospital-owned and health plan-owned clinics should be able to fulfill many of the criteria. They may share similar goals, including patient-centered care and incentives for cost-containment, and they should readily be able to share information with the primary care clinic, ideally through the same EHR.  A solid physician-owned urgent care clinic may not have the relationships already in place but would likely have motivation to do so. Non-physician owned and franchise UC clinics may have less of the relationships and systems in place and may have less incentive to do so, focusing more often on the business aspects than the medical community as a whole. In time, as the medical home becomes a larger factor in healthcare, these clinics may need to adapt to succeed.

Conclusion

As discussed, both urgent care and the medical home are becoming part of the new norm for healthcare. While quite distinct, they can both contribute to the goal of a healthier community. The medical home aims to be the foundation for a patient and family’s overall health and well-being, while urgent care fits the needs of busy working families and fills the gaps of accessibility and convenience, especially for the many things that can happen after 5 pm. In addition, urgent care possesses some attractive features of the medical home that primary care often lacks and may look to adopt, such as convenient access and timely care. A pediatric clinic recently posted a blog discouraging their patients from seeking care from urgent care, especially retail clinics, and reminded them of the availability of same day appointments and a 24 hour nurse line. They specifically mentioned the importance of the medical home, but were also likely concerned about competition for patients that urgent care clinics create. In turn, this competition likely encouraged the primary care clinic to increase attractive features offered to their patients to make the medical home more convenient and accessible. In this case, urgent care can not only play a role in the medical home, but can actually improve it.

References:

http://www.hrsa.gov/healthit/toolbox/Childrenstoolbox/BuildingMedicalHome/whyimportant.html

Scott DR, Batal HA, Majere S, et al. Access and care issues in urban urgent care clinic patients. BMC Health Serv Res. 2009; 9: 222. http://www.biomedcentral.com/1472-6963/9/222.

Weinick RM, Burns RM, Mehrotra A. How Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics? Health Aff (Millwood). Sep 2010; 29(9): 1630–1636. http://www.ncbi.nlm.nih.gov/pubmed/20820018.

Bell, T. The Growing Business of Urgent Care. Med Monthly. Aug 2014. http://medmonthly.com/insight/the-growing-business-of-urgent-care/

Creswell J. Race Is On to Profit From Rise of Urgent Care. The New York Times. July 9, 2014. http://www.nytimes.com/2014/07/10/business/race-is-on-to-profit-from-rise-of-urgent-care.html?_r=0

By Laura E. Marusinec, MD, Urgent Care Pediatrician

Laura Marusinec is a board-certified pediatrician with experience in general pediatrics, pediatric dermatology, and pediatric urgent care. She has supported an electronic health record implementation and optimization and is pursuing further medical writing education and opportunities.

Leave a Comment

Please type the characters of this captcha image in the input box

Please type the characters of this captcha image in the input box