Study finds tensions between medical homes and being patient-centered

November 12, 2015

A study co-authored by a UNC Gillings School of Public Health researcher and published Oct. 9 in the journal Social Science & Medicine describes how North Carolina incorporated case management for low-income pregnant women and young children into the state’s Medicaid managed care network.

Dr. Dorothy Cilenti

Dorothy Cilenti, DrPH, clinical assistant professor of maternal and child health at the Gillings School, co-authored the study with L. Michele Issel, PhD, public health systems scholar at UNC-Charlotte, and Rebecca Wells, PhD, formerly on the health policy and management faculty at the Gillings School and now professor of health policy and management at the University of Texas School of Public Health.

The researchers aimed to understand the implementation of a recent statewide policy that required maternal and child case management to be integrated into a medical home model. A medical home model is a system of delivering comprehensive and continuous medical care to patients with the goal of maximizing health.

In an effort to better use public funding to improve outcomes for vulnerable populations, the state policy required public and private organizations to collaborate more closely and to focus on the physical needs of those served. The policy reflected an ideological change in state services, which previously had been more broadly based.

Results from site visits to four local health departments before and after the policy change suggest that the state successfully increased connections between health departments and external providers. However, in the medical home model, mothers reported having less input into the care of themselves and their children, and health departments reported seeing needs that could not be met within the guidelines of the new program.

Mothers interviewed for the study emphasized how much they appreciated case managers’ personal concern for them. In the new medical homes model, however, case management was tied more explicitly to medical necessity and Medicaid eligibility. Health department staff members worked, with variable success, to improve communication with providers. They also reported occasionally serving women who did not meet official program criteria, justifying their actions as being grounded in public health values.

In North Carolina, as in other states, legislators continue to grapple with how best to meet the health needs of economically vulnerable populations.

“Other states can learn from North Carolina’s experiments in improving the safety net,” noted lead author Wells.

“Focusing Medicaid policies on enabling clinicians to address medical needs makes sense because Medicaid is health insurance, and states have to balance their budgets every year,” Cilenti said. “However, health is affected by many factors that interact over people’s lifetimes. Health departments often have served as hubs of local safety nets. Policies that sustain public agencies and build their connections to private providers ultimately may be the most effective.”

The study was funded by the Robert Wood Johnson Foundation through its Practice-Based Research Network in Public Health.