Monday, September 28, 2015

Home is where the chart is

I thought molecular biology was complex until I recently ventured into the world of etymology in search of the origin of the word ‘home’.

If you share my interest in this topic, then please take a look at the Oxford University Press blog by Anatoly Lieberman1, a multilingual 78-year-old teacher of etymology, linguistics and folklore at the University of Minnesota.

He begins with a scholarly and intricate exploration of the words ‘house’ and ‘home’ by writing: “When it comes to origins, we know as little about home as we do about house.”

Perhaps because of the mystery surrounding the origin of the word home, it is powerful, and we need to be careful how we use it.

So, what does it mean?

As Verlyn Klinkenborg, an Iowan non-fiction writer of rural literary meditations, wrote in the Smithsonian magazine in 2012:
“Our psychological habitat is shaped by … the magnetic property of home: the way it aligns everything around us. Perhaps you remember a moment, coming home from a trip, when the house you call home looked, for a moment, like just another house on a street full of houses. For a fraction of a second, you could see your home as a stranger might see it. But then the illusion faded, and your house became home again. That, I think, is one of the most basic meanings of home — a place we can never see with a stranger’s eyes for more than a moment.”2
Despite the word having such an uncertain origin and complex meaning, there’s currently much discussion within general practice about the idea of the ‘medical home’, which is portrayed as an attractive place, not to be confused with a nursing home or an institution for the residential care of people with severe disabilities. But not everyone with whom I have spoken likes the concept.

One such person said to me: “Frankly, I find the idea creepy. It seems to be appropriating an idea (home) that implies warmth and comfort and security to refer to a place where you go when you are ill, insecure and frightened.”

Related News:
Where has the medical home concept come from? According to Wikipedia, it was first articulated by the American Academy of Pediatrics in 1967 to offer co-ordinated care for children and their families, especially those with special needs.

The idea has since gathered support.

Now there is a list of qualities that medical home practices must demonstrate in order to be accredited. According to the rules, they must be places where each patient has their own doctor who leads a multidisciplinary team that can meet the individual needs of the patient.

High standards of quality and safety must be adhered to, and performance is formally assessed against these standards. Payment “appropriately recognises the added value provided to patients who have a patient-centred medical home”.

Put simply, the medical home is a place where a patient is known personally by name and history and where a team of health professionals, generally led by a GP, arranges and provides the patient with the care they need.

Related Opinion:
At its best, it is about knowing the patient, honouring their identity and knowing their unique health and illness profile and then building on that knowledge whenever a medical transaction takes place.

Going beyond the group practice, the medical home is designed to bring together professionals from different disciplines.

Yet, where a group practice adds in a nurse and other health professionals to meet patients’ needs, in a medical home (at least as formally defined and not as an indefinite and warmly fuzzy idea), these services are more formally organised and paid for.

This has special salience for people with multiple long-term problems, who make up around 30% of the general practice patient population. But we need to be careful because attractive concepts — such as co-ordinated care, which has been trialled here over recent decades — can be disappointing.

There are other issues too, such as the successful co-ordination of carer services, both in hospital and at home. This is a serious management task, and not many doctors have undergone the necessary training to take on this role.

Hospitals are in a relatively strong position because of their infrastructure and range of specialties. For a GP, matching this level of service is going to be extremely challenging, unless he or she has a back-up organisation, such as a group practice.

So by all means, let’s discuss the medical home as a way to provide better personalised, stitched-up care. But let’s be careful: powerful words misused have a habit of coming back to bite you. Beware of overpromising and trampling on sacred ground.

Professor Leeder is Emeritus Professor at the Menzies Centre for Health Policy at the University of Sydney.

References:
  1. Oxford University Press blog 2015; Our habitat: one more etymology brought “home”; Anatoly Liberman.
  2. Smithsonian magazine 2012; The definition of home; Verlyn Klinkenborg.
Published in Australian Doctor 28 September 2015

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