The interventions were not telephone therapy, says Michael Klinkman, MD, a professor of family medicine at the University of Michigan Medical School and lead author of the study. The key was to keep patient in treatment. "Patients have a human contact, somebody who can help them become more actively involved in their own care."
With this care management approach, physicians can closely monitor if a patient's condition is worsening. In many cases, patients simply don't follow up—in this case, physicians take the initiative.
For this study, a care manager worked in collaboration with doctors' practices, rather than on the side or independently. That helped make the family practice office a home base for all of a patient's medical needs—a medical home.
That's not accidental: The intervention fits "exactly into the context of the patient-centered medical home," Kinkman says.
It's a patient-centered, rather than a disease-centered approach, he adds.
"As this program has developed over the years, we increasingly realize that its core components—patient activation, self-management instruction, goal-setting and priority-setting, and individualized follow-up—work on the person level, rather than the disease level," he explains. When we began, it was difficult to get outside support for interventions that were not disease-based. As the concept of the PCMH has taken hold, it's a natural extension of the program since the majority of the patients referred to the DPC program have more than one condition.