1. Issel, L. Michele PhD, RN

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The buzz about medical homes continues across the health care field. Aside from the reality that no one wants to live in such a home, the notion sounds more like a recycled concept than something newly created. The concept is that a primary care provider is the center of coordinating care in collaboration with the patient. By embracing patient-centeredness, the focus shifts from the provider to the needs of the patient. Those of us who have been in health care for a while will recognize these ideas as also having been lauded in the early days of the primary care specialty and of managed care arrangements and having originated out of concern for the medical care for children with special health care needs.

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Many of the problems and forces driving our attention toward the patient have persisted. To some extent, diagnosis and treatment have become too complex for a single provider to initiate and implement. With multiple providers involved in the medical care of any one patient, various aspects of the care delivered by the different providers need to be orchestrated by someone in order to minimize costs and maximize health benefits. In addition, individuals and society continue to want the highest quality medical care at the lowest cost, perpetuating a fundamental dilemma, if not a paradox. Lastly, but far from least, garbage can decision making persists, along with the associated disconnect between research-based evidence for medical and managerial practice and those practitioners and policy makers. Obviously, I dramatized the situational context to stress the point that the issues underlying the medical home buzz may not be fully redressed by the implementation of medical homes.


Over the same time, the organizational and informational infrastructure of the health care system within which the orchestration must occur has evolved in some fundamental ways. Facilities have grown in size. Now, health care systems dominate rather than hospitals as independent entities. Information technology facilitates real-time communication among the health care providers and patients but does not necessarily overcome the known and hidden health disparities and cultural barriers to achieving optimal health.


This is the question that continues to nag both researchers and practitioners: What makes care coordination and patient centeredness so attractive and yet so difficult to attain and maintain? In many ways, this question lies at the heart of health care management science. The question of how to achieve health care and medical care coordination sits at the intersection of understanding individual behaviors, whether medical providers or health care mangers, and the influences of the micro-, mezzo-, and macrosystem dynamics on those behaviors. The cost-quality paradox sits at the same intersection. The next generation of health care management research must contextualize behaviors of providers, managers, and patients to unravel the complexity of interactions among those actors within the dynamics of health care systems. As that body of research expands our awareness, we must be open to the possibility that evidence-based solutions are local, while those solutions might be conceptually universal. From this perspective, the medical home is a rose with its local variants while belonging to a family. Understanding the ecosystems in which care coordination flourishes will have benefits beyond giving the rose a sweet fragrance.


L. Michele Issel, PhD, RN