Overview of
Patient Centered Medical Home
Susan Dezavelle, RN, Medical Informatics
Presbyterian Health Plan
June 2011
Patient Centered Medical Home
Definition: An approach to providing comprehensive
primary care with the goal to pro-actively manage
a population of patients
Guidelines:
 Team approach to care
 Patients actively involved in care
 Coordinating care across systems
 Maximize health information (EHR)
 Performance measurement and quality improvement
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Patient Centered Medical Home Methods
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Alternative venues of care (e-visits, telephone, group)
Team “visits” – warm hand offs, Nurse, BH,
Pharmacist
Pre-visit planning and follow up between visits
Outreach to patients with chronic conditions
Automated processes to follow up for preventive
health
Effective use of EHR as registries, e-prescribing
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Patient Centered Medical Home Methods
– Consistent and timely follow up on diagnostic testing
– Immediate follow up on ER and inpatient admissions
– Coordination with specialists and other care systems
– Systematic measurements of processes and outcomes
– Evaluation of interventions and process improvements
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PCMH Drawing National Attention
Nationally recognized as a new model of care
Recognition that Primary Care can impact cost and quality
Programs in several states over the past 5 – 8 years
Measurements starting to show impact
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NCQA PCMH Recognition Program
Application to NCQA is extensive
Designate Levels 1 through 3, typically Level 3 requires
EMR to meet standards (not required)
Standards are self reported
Focus on quality, chronic care and prevention and
coordination of care
Encourages measurements, primarily for quality
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What NCQA Recognition Is Not
Recognition does not ensure actual practice
transformation
Practice transformation can occur without NCQA program
Does not specifically address utilization or cost
management
Does not guarantee payment for care management will be
sustainable
Is not an “Accreditation” program
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State of New Mexico Mandate for PCMH
State Law passed in early 2008 includes requirement for
managed care Medicaid to pilot PCMH
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Pay for Performance (P4P) now linked to PCMH
initiatives
Included in the HSD contract language
Purpose: to determine methods by which PCMH programs
can be effectively implemented in New Mexico
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State of New Mexico Mandate for PCMH
Health Plans are required to:
– Encourage NCQA Recognition
– Provide consultative services
– Provide financial assistance to develop programs
– Track quality and utilization measures and expect
improvement
– Move towards new reimbursement models
– Obtain approval from HSD for each program
– Report funding to HSD
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Presbyterian’s PCMH Vision
Presbyterian Health Plan (PHP) supports the
transformation of primary care delivery and
reimbursement following national Patient Centered
Medical Home principles to improve quality and cost
management, using a team approach and
comprehensive care coordination.
PHP supports primary care practices promoting a
population based view, globally managing healthy and
chronically ill patients, leveraging systems to identify and
reach out to patients, develop more efficient ways to
deliver and coordinate care, while transitioning to utilizing
electronic health information in their practice.
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Presbyterian’s PCMH Programs
Started in late 2009
Currently have four PCP Groups participating
Each has a written agreement, specific expectations,
quality and utilization measures with targets
Sharing data and reports and tools to manage targeted
conditions and utilization measures
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Presbyterian’s Lessons Learned
– If you’ve seen one PCMH program, you’ve seen one
PCMH program – they are all unique
– Consider the administrative burden for the PCP groups
– Important to stay focused on outcome measures and
interventions to impact
– Care coordination is the key – it’s a new skill
– Importance of data analysis and reporting
– Patient paneling issues
– How to incorporate physician involvement and
engagement
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Questions?
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