Langston says an example of what he means is the IMPACT intervention model of evidence-based depression care that the Hartford Foundation trialed almost 10 years ago. IMPACT uses a lot of the structural elements of the medical home: a patient registry, structured assessment tools, a nurse to work the registry, and a particular depression scale that is reapplied to patients later in their care to understand whether they're getting better or not.
"Like with the PCMH, you have to know how to use it and what the rules are. For example, if someone doesn't improve in four weeks, we'll change their dose," he says, to illustrate the specificity of follow up care necessary to fully take advantage of the medical home's capabilities. "That's the kind of 'furniture' that I don't think the PCMH provides overall. The structure needs to be filled in in a fairly systematic and thoughtful way."
According to a 2002 study in JAMA, IMPACT more than doubles the effectiveness of depression treatment for older adults in primary care settings. And patients receiving this type of care had lower average costs for their medical care—about $3,300 less even after factoring in the extra cost of IMPACT care—than patients receiving usual care.
The lesson, according to Langston: Don't evaluate things before they're ready. Second, even if every practice had been at Level III, it really matters what the clinical content is, and most practices are not good enough inventing that on their own; they need help.