Patient-Centered Medical Home
Presented by
Dawn Foster Jeffries
November 18, 2010
Patient-Centered Medical Home
• Patient-Centered Medical Home (PCMH) is
defined “… as a team of people embedded in the
community who seek to improve the health and
healing of the people in that community… Unlike
more narrowly focused ways of organizing the
delivery of commodities of healthcare, the PCMH
aims to personalize, prioritize and integrate care to
improve the health of whole people, families,
communities and populations.”
Source: K.C. Stange, P.A. Nutting, W.L. Miller et al., “Defining and Measuring the
Patient-Centered Medical Home,” Journal of General Internal Medicine, June 2010
25(6):601-12.
Patient-Centered Medical Home
• “The Patient Centered Medical Home
(PCMH) is a model of primary care delivery in
which patients receive well-coordinated
services, evidence based care, and
enhanced access to a clinical team.”
Source: The Commonwealth Fund, Qualis Health, and the MacColl Institute for
Healthcare Innovation, “RCC Recruiting Tool,” September 2008, Retrieved from
http://www.qhmedicalhome.org/safety-net/upload/RCC-Recruiting-Tool08-0903.doc
Joint Principles of the PatientCentered Medical Home
1) Patients have continuous relationships with “personal
physicians”
2) The care team takes “responsibility for the ongoing care of
patients” and is led by a “physician”
3) The practice has a whole person orientation and coordinates
care that cannot received at the practice
4) Care is integrated and coordinated
5) “Quality and safety are hallmarks”
6) “Enhanced access to care is available through systems” and
new communication options
7) Payment for PCMH
Source: American Academy of Family Physicians (AAFP), American Academy of
Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic
Association (AOA), “Joint Principles of the Patient Centered Medical Home,” PatientCentered Primary Care Collaborative, February 2007.
National Recognition and
Accreditation Programs
Recognition and Accreditation
• National Committee for Quality Assurance Physician
Practice Connections® Patient-Centered Medical
Home™
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Access & Communication
Patient Tracking & Registry
Care Management
Patient Self-Management Support
Electronic Prescribing
Test Tracking
Referral Tracking
Performance Reporting & Improvement
Advanced Electronic Communication
http://www.ncqa.org/tabid/631/default.aspx
Recognition and Accreditation
• The Accreditation Association for Ambulatory
Health Care offers Medical Home
Accreditation
– On-site survey of staff, facility, equipment,
medical procedures and care coordination
procedures
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Relationship with patient
Continuity, comprehensiveness, and accessibility of care
Electronic data management
Quality, physician-directed care with routine assessment of
evidence-based guidelines and performance measures
http://www.aaahc.org/eweb/dynamicpage.aspx?webcode=mha
Recognition and Accreditation
• The Joint Commission
– Primary Care Home
• Under development
• An option to be part of accreditation of ambulatory
health care organizations
• Available in the spring of 2011
Source: E.E. Zhani, “The Joint Commission Developing Primary Care Home
Option,” The Joint Commission, October 8, 2010, Retrieved from
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_09_07_10.htm
PCMH Legislation, Pilots, and
Projects in the United States
PCMH Across the U.S.
• “Some 44 states and the District of
Columbia have passed more than 330
laws relating to the medical home, or have
executive level activity that references the
PCMH.”
Source: Patient-Centered Primary Care Collaborative, “Federal and State
Government,” Retrieved from http://www.pcpcc.net/federal-and-state-government
PCMH Pilots and Demonstration Projects
Alabama
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Nebraska
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
http://www.pcpcc.net/content/pcpcc_pilot_report.pdf
Safety Net Medical Home
Initiative
SNMHI Aims of the PCMH
• At the clinical level:
– Improve the operational efficiency
– Improve quality of care in primary care clinics
– Improve patients’ healthcare experiences
– Reduce disparities in access to care and
quality of care
SNMHI Aims of the PCMH
• At the regional level:
– Enhance regional capacity to support and
sustain practice improvements
– Influence health policy by involving Medicaid
and other stakeholders in action towards
appropriate reimbursement levels
Safety Net Medical Home Initiative
Change Concepts
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Empanelment
Continuous and Team-Based Healing Relationships
Patient-Centered Interactions
Engaged Leadership
Quality Improvement Strategy
Enhanced Access
Care Coordination
Organized, Evidence-Based Care
Source: Qualis Health, The Commonwealth Fund, and MacColl Institute at Group
Health Collaborative, “Change Concepts for Practice Transformation,” The Safety
Net Medical Home Initiative, Retrieved from http://www.qhmedical home.org/safetynet/change-concepts.cfm
SNMHI Technical Assistance
Facilitation of “community
of practice”: sharing best
practices among sites
Data collection and
reporting, practice
coaching, QI consultation
Webinars, electronic and
telephonic communication
with sites
Technical consultation from
experts in specific domains of
the change concepts
How to Begin
PCMH Transformation
First Steps
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Engage leadership
Form a PCMH workgroup
Write down the vision for PCMH
Identify PCMH goals
Identify PCMH measures
Identify a quality improvement strategy
Identify a data collection strategy
Milestones
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Ensure all staff understand PCMH
Engage staff in PCMH changes
Ensure patients understand PCMH
Engage patients in PCMH changes
Tools and Resources
Accreditation Association for Ambulatory Health Care
http://www.aaahc.org/eweb/dynamicpage.aspx?webcode=mha
Center for Medical Home Improvement
http://www.medicalhomeimprovement.org/
The Joint Commission
http://www.jointcommission.org/AccreditationPrograms/AmbulatoryCare/Primary+
Care+Home+Initiative/
National Committee for Quality Assurance
http://www.ncqa.org/tabid/1034/Default.aspx
Patient-Centered Primary Care Collaborative
http://www.pcpcc.net/
Thank you!
Dawn Foster Jeffries
Colorado Community Health Network
dawn@cchn.org
600 Grant Street, Suite 800
Denver, CO 80203
(303) 861-5165