Medical Home Concept: Policy Implications for an Integrated Approach in Obesity Management

Introduction

Obesity is a serious chronic health problem with increasing public health implications. In 2006, the World Health Organization (WHO) indicated that there were 1.6 billion overweight adults and at least 400 million obese adults worldwide. ¹ Furthermore, there are approximately 93 million obese Americans with projections for this number to increase to 120 million by 2015. ² Closely associated with obesity are comorbid diseases, including cardiovascular disease, diabetes, musculoskeletal disorders, and endometrial, breast, and colon cancers. ¹ These conditions carry high health and economic burdens of suffering that can be significantly impacted through obesity management and treatment. One study ³ has demonstrated that bariatric intervention and subsequent weight loss improved the physiologic outcomes related to diabetes, hyperlipidemia, sleep apnea, impaired glucose tolerance, and hypertension at 1- and 2-year postoperative follow-up. This study demonstrated an average savings of $1,300 per patient year through decreased healthcare usage rates.

Despite these positive findings, the coordination of obesity management remains a policy and management challenge. Who is responsible for the overall coordination of these complex clients? This important policy answer may lie in the current medical home demonstration projects.^4–6

Medical Home

The medical home concept was first introduced by the American Academy of Pediatrics ⁵ as a model of care to coordinate accessible, comprehensive, continuous, and culturally effective primary healthcare to vulnerable pediatric populations. This same model can be used to coordinate primary healthcare services to coordinate the spectrum of healthcare services to vulnerable obese and morbidly obese clients.

Medical home concepts have gained momentum with recent legislative efforts geared toward healthcare reform. Much attention has been given to language revisions of current legislation to ensure inclusion of all primary care providers in medical home demonstration projects.^4,5 It is essential that legislative efforts include enabling language for all eligible primary care providers who may be involved in obesity management to participate in medical home demonstration projects.

Primary Care Providers

Policy attention to removal of clinical practice barriers and coordinated, integrated care is not a new concept. Several seminal studies^7–10 call for a standardized regulatory environment and scope of practice enabling certified nurse midwives, nurse practitioners, physicians, and physician's assistants to serve as primary care providers. These primary care providers serve as the gatekeepers to primary healthcare, including but not limited to obesity management.

Clients who lack access to basic primary care have poorer healthcare outcomes and are less likely to receive preventive healthcare. ¹¹ Complications from untreated obesity complications go unchecked when clients do not have coordinated primary care services. When they do receive treatment, they are more likely to be diagnosed with costlier and more severe health problems that lead to increased morbidity and premature death.^11,12 When obese clients received coordinated and integrated care, a spectrum of management options are at their disposal; these options range from primary prevention to bariatric surgical intervention with proven healthcare outcomes. ⁶

It is imperative that obese and morbidly obese clients have access to qualified primary care providers in a coordinated, coherent, integrated system. However, obesity management requires a multidisciplinary approach that requires the primary care provider coordinate care with the appropriate obesity specialists.

Integrated Care Coordination

Primary care providers coordinate the spectrum of primary healthcare services. Obesity is a primary care issue with multidisciplinary aspects to the patient's care. The medical home concept is an excellent model to enable all primary care providers to provide accessible, integrated, coordinated healthcare services. Policy and legislative efforts must support and enable a team of qualified healthcare providers to meet the complex needs of obese and morbidly obese clients. Multidisciplinary team members include primary care providers, bariatric nurse coordinators, registered dietitians, mental health specialists, exercise physiologists, physical therapists, endocrinologists, and bariatric surgeons. ¹³ Just as it takes a neighborhood to raise a child, it takes a multidisciplinary team to optimally manage the needs of obese and morbidly obese clients. The center of the multidisciplinary team is the primary care provider coordinating the medical home services.

Conclusion

Obesity is a complex public health issue requiring an accessible, coordinated, integrated model of care. The medical home concept is a policy solution to ensure that all primary care providers are enabled to provide these important services in the coordinated management of the spectrum of obesity issues. Diligence is required to ensure that evolving legislative language enables all qualified primary care providers to participate in the medical home demonstration projects. Primary care providers are the central gatekeepers in obesity management but, indeed, it takes a team to successfully manage the full spectrum of healthcare for obese and morbidly obese clients. Policy decisions supporting the role of qualified primary care providers in the coordination of services for obese clients is the foundation for accessible, coordinated, integrated, culturally appropriate care for obese and morbidly obese clients.