Practice Perspective Explains Medical Home Model Concept

NASW has developed a new practice perspective guide, “The Medical Home Model: What Is It and How Do Social Workers Fit In?”

Written by Stacy Collins, NASW senior practice associate, the document explains the history of the medical home concept and its recent rise in popularity.

Early evidence suggests that this model has the potential to improve client care — while also reducing health care expenditures — by minimizing emergency room visits and hospitalizations, improving adherence to treatment plans and other cost-saving measures, the document explains.

The Agency for Healthcare Research and Quality describes a medical home as a model for organizing primary care that meets the majority of the client’s physical and mental health care needs. The team can comprise physicians, advanced practice nurses, physician assistants, nurses, social workers and pharmacists.

The practice perspective says the Affordable Health Care Act of 2010 promotes a shared accountability model for improving patient care while also controlling costs for a defined population.

“Social workers are well positioned to participate in these health delivery models — and have demonstrated their value in many medical home demonstration projects currently under way throughout the nation,” the practice perspective states.

The medical home can range from a small group to a large-scale endeavor involving federal agencies, such as the Department of Veterans Affairs.

Patient-centered medical home care works best when care coordination among the interdisciplinary teams is on the same page.

“Care coordination is central to the shift in orientation away from a focus on episodic acute care to a focus on managing illness and facilitating preventative self-care, especially for those with chronic health conditions,” the practice perspective states.

It notes that social workers provide a valuable resource to the medical home. For example, social workers can ensure that nonmedical factors affecting the client’s well-being, such as environmental and psychosocial needs, are being met.

“Moreover, the social work profession’s ecological framework promotes intervention on both individual and systemic levels,” it explains.

The practice perspective also highlights several initiatives taking place regarding the role of social work in the medical home, such as the University of Oklahoma School of Community Medicine’s Patient-Centered Medical Home Project.

The guide offers suggestions on what social workers can do to promote medical homes, including:

  • Insist that medical home projects include prevention and treatment of mental illness and substance use disorders, along with chronic disease management.
  • Engage families and consumers in promoting the concept and partner with key stakeholders, such as Medicare and Medicaid programs, provider and payor organizations, patient advocacy organizations and other groups who support the concept.

Collins said a stronger focus on primary care through the medical home model won’t result in cost savings unless these programs address patients’ psychosocial needs. “Social workers are trained to do just that,” she said.

The practice perspective also provides a listing of resources and references for more detailed information, as well as recent publications produced by the NASW Center for Workforce Studies and Social Work Practice.

“The Medical Home Model: What Is It and How Do Social Workers Fit In?” is at: {}