An oft-cited reason for people not getting timely screenings and for poor management of chronic conditions is that the healthcare many people receive is fragmented. In recent years, policy experts and clinicians alike have embraced a "medical home" model of primary care that takes a back-to-the-future approach in which patients' primary-care doctors are responsible for managing their healthcare, not just the particular issues that arise in a brief office visit. Medical home practices often employ a team approach to managing care and keep close tabs on their patients with high-tech information technology.
Medical homes also strive to enhance access to care, and patients can often communicate with their doctors by E-mail or make same-day appointments. The American Academy of Family Physicians sponsored 36 medical home practices as part of its TransforMED demonstration project; other professional groups are also experimenting with the model. Geisinger Health System in Pennsylvania reduced hospital admissions by 20 percent and trimmed medical spending by 7 percent by using a medical home model of care, according to a study in the September/October 2008 issue of the journal Health Affairs. But such practices are still rare, and it's too soon to know how they might affect healthcare delivery or costs overall.
At Harbor of Health, a primary-care practice in Memphis that is one of the TransforMED demonstration sites, there are only four chairs in the waiting room. Everybody gets same-day appointments, and patients are whisked into the exam room within five minutes, according to Susan Nelson, one of the physicians there. Even though she spends more time one-on-one with her patients now, they are in and out of the office in just 45 minutes, compared with nearly an hour before. "It's labor-intensive, because you have to be a health coach, and people don't want to exercise or diet," says Nelson.
Homegrown. How we organize our communities and even our own homes may have as great an impact on our health as the way our healthcare system is structured. Communities without sidewalks or bike paths offer little encouragement for people to rely less on their cars. School cafeterias that serve french fries and sugary sodas tempt kids with unhealthful lunch choices.
Rather than leaving it up to individuals to make healthful decisions about diet and exercise, researchers are taking aim at our physical and social environments. "If we can start to shift our systems, it will go a lot farther than trying to reach 300 million people one-on-one," says Christina Economos, an assistant professor at the Friedman School of Nutrition Science and Policy at Tufts University.
Economos led the "Shape Up Somerville" study, a three-year CDC-funded childhood obesity intervention in which researchers worked with the city of Somerville, Mass., to make it easier for children to "eat right, play hard," as the study's slogan puts it. Over the course of two years, school cafeterias—and even local restaurants—changed menus to offer more fruits, grains, and veg-etables. Fatty snacks and sugary drinks were eliminated from lunchrooms. Parents were encouraged to take televisions out of kids' bedrooms. Bike racks were installed at the schools, and trees were planted to create leafy shade over the sidewalks. The changes worked: The city's first through third graders gained a pound less during each of the two years than their peers in two control communities.
But the changes didn't end when the study finished in 2005. Somerville has continued to alter its environment to encourage people to eat smart and play hard, including extending bike paths, creating new parks, and opening farmers' markets.
"This is not about going on a diet," says Somerville Mayor Joseph Curtatone. "This is about social change. We're changing the culture and behavior of people to get them to move in another direction." The reality is, getting Americans to move at all would be a good first step toward health improvement. The nation's new health coach in chief, clearly, has his work cut out for him.