How do you know when your practice is a Patient Centered Medical Home?
By Elizabeth Kraft, MD
In the quality arena, the adage goes: “What gets measured, gets monitored and what gets monitored, gets improved.” In the past several issues of CAFP News, there has been discussion about the patient centered medical home, or PCMH. In brief, the PCMH is a practice that has at its core an on-going partnership between a patient and the patient’s family and the physician. The personal physician leads a clinical office practice team and assists the patient in navigating the health care system with coordinated and integrated care processes. This includes the use of evidence-based guidelines, referral coordination, cross-cultural sensitivity and a platform of health information technology. The practice provides accessible, family-centered, continuous care in a whole person orientation.
While it seems apparent that family physicians are finally getting recognized for their efforts in having provided this integrated health care all along, especially for patients with chronic illnesses, how does one know what is a PCMH? How do you know when your practice is a PCMH? How do you describe what makes a PCMH and can you measure what you have described? Why do you need to measure what you do as a Family Medicine physician? And, if you are to measure yourself as a PCMH, if you find areas that need improvement, are you willing to devote resources to improve?
While the PCMH is not a new concept, the creation of a uniform set of measures applicable across all specialties has recently been put forth by a national organization called NCQA. On Jan. 2, 2008, NCQA (National Committee for Quality Assurance) released a set of measures that have been endorsed by the AAP (American Academy of Pediatrics), AAFP (American Academy of Family Physicians), ACP (American College of Physicians), and the AOA (American Osteopathic Association), called PPC-PCMH (Physician Practice Connections-Patient Centered Medical Home). Building on the joint principles developed by these primary care specialty societies, the PPC-PCMH standards emphasize the use of a personal physician; physician-directed medical practice; whole person orientation; systematic, quality and safety features; and coordinated care management processes with enhanced access.
These measures are organized into nine standards that serve to describe and to measure the intent of what a PPC-PCMH should consist of: access and communication, patient tracking and registry functions, care management, patient self-management supports, electronic prescribing, test tracking, referral tracking, performance reporting, and advanced electronic communication. A practice can apply to NCQA for PCMH recognition; this entails submission of documentation that validates that the practice includes these aspects as part of the routine delivery of health care according to their standards. There are three levels of recognition, based upon the total number of points scored. There are several of these standards that are called “must pass” -- those standards must be incorporated into a practice in order to be recognized as a medical home.
Across the country, there have been pilot projects supported by Medicare, Medicaid and, in some states, by employers and health plans. In Colorado, Senate Bill 07-130, passed into law in 2007, mandates that all children in public health programs, Medicaid and SCHIP, have a PCMH available to them. Work teams of representatives from Family Medicine, pediatrics, mental health, oral health, families, and specialty medicine have been developing standards to help define the principles of the medical home and, ultimately, to objectively identify a medical home in practices that serve Medicaid and SCHIP children. Alignment of these standards with those of NCQA, those that have already been worked on by national advocacy groups, as well as additional measures that accurately reflect practice activities, such as patient centered, culturally sensitive, and compassionate care, are being considered.
NCQA has four other recognition programs for practitioners/practices that recognize a patient-centered approach and deliver care in accordance with widely accepted evidence-based guidelines: the Diabetes Physician Recognition Program (DPRP), the Back Pain Recognition Program (BPRP), the Heart/Stroke Recognition Program (HSRP) and PPC (Physician Practice Connections).
The value of achieving recognition for these programs comes to a Family Medicine doctor in many ways: achievement of DPRP and HSRP may allow credit on portions of the Maintenance of Certification for board certification. Employers desire to have their employees select doctors based upon quality -- the NCQA recognition program and board certification are available proxies. For example, in the fall of 2007, in the CBGH (Colorado Business Group on Health) “Health Matters” publication, a guide for employers and employees to select a health plan, placed the photographs of those doctors in Colorado who achieved DPRP recognition. Another plus for Family Physicians is that organizations or health plans may offer extra cash to physicians for participating in pay-for-performance programs or medical home pilot projects.
The AAFP is gearing up to offer assistance to support practices in working toward these recognition awards. The AAFP's Practice Support Division, its Center for Health Information Technology, and TransforMED, a practice redesign initiative affiliated with the academy, are three resources members could use. In Colorado, CCGC, Colorado Clinical Guidelines Collaborative, has been working with practices through the IPIP (Improving Performance in Practice) with in-office quality coaches to assist practices in redesign efforts to treat chronic illnesses such as asthma and diabetes, along the planned or Ed Wagner’s chronic care model.
A good web page with many links is http://www.aafp.org/online/en/home/publications/news/news-now/practice-management/20080207ncqa-pcmh.html. Visit the CCGC website www.coloradoguidelines.org) to learn more about the IPIP project and how to apply to be an IPIP practice.
As there will be an ever increasing focus on quality measures at the practice and physician level, understanding what these measures and standards are and seeking to incorporate them will place your practice ahead of the curve.
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Medical Home – Of course we want it, but what is it exactly?
Medical Home – it’s a term we are hearing everywhere these days—from professional journals to the Wall Street Journal to local papers across the country. Led by the patient’s personal physician, the medical home concept puts the patient at the center of an integrated health care team capable of addressing the patient’s every routine health care need. Purporting to improve patient outcomes while reducing costs, it is like motherhood, apple pie and a day at the spa rolled into one. Sounds great, right?
But what exactly is a medical home? What does it look like? How will you know one when you see one? A medical home is not a building or a structure. At the most basic level it is a method of health care delivery; a method surprisingly similar to the idyllic image of medicine that drew most primary care physicians into the field. Imagine a primary care physician playing quarterback and wearing the number 7, leading a well orchestrated team of highly trained staff, providers and specialists towards the goal of patient welfare, and you begin to see the potential of a medical home.
The concept began with the American Academy of Pediatrics many years ago and gained national momentum when the other national primary care societies (American Academy of Family Physicians, American College of Physicians, and the American Osteopathic Society) joined forces. Together they published “The Joint Principles of a Patient Centered Medical Home” (see box). AAFP has been a prime mover in bringing the concept to reality at the national level.
Working with the primary care societies, NCQA, the National Committee for Quality Assurance, developed a set of standards to measure “medical homeness.” Measures include:
- Ease of access and communication;
- Patient population tracking and registry functionality;
- Proactive self-management support;
- Performance reporting and continuous quality improvement processes;
- Test and referral tracking; and
- Access to advanced electronic communication resources.
To receive NCQA recognition as a medical home a practice must demonstrate it has the systems and tools in place to coordinate patient care across the clinical spectrum, while empowering patients to self-manage their chronic conditions and support their efforts to make good choices.
When Colorado Senate Bill 130 was signed into law last year the state pledged to provide the children covered by Medicaid and SCHIP, and their families, with continuous, accessible, and comprehensive medical and nonmedical services. A multi stakeholder task force is currently working to define the standards for a medical home for Colorado.
While physicians agree that they would like to provide this kind of care, the reality of today’s health care environment is a major deterrent. The proliferation of medical knowledge, the complexity and fragmentation of the health care system, the unpaid and overwhelming administrative demands on primary care, a compensation system that does not reimburse for coordinating care, and patients who change providers regularly because of insurance changes are all significant barriers.
For medical homes to achieve their potential, significant changes at the practice level and the health care system level are necessary. At the practice level, there needs to be:
- An engaged, empowered health care team to actively collaborate with the physician to assure the delivery of evidenced-based guidelines at the point of care;
- An electronic information system (either an EMR or stand-alone registry) to track patients for effective management of chronic conditions and preventive medicine;
- An outreach system to identify and notify patients when care gaps occur;
- A reliable process for providing self-management support; and
- A system for reporting and reviewing performance measures to assure continuous performance improvement.
Colorado Clinical Guidelines Collaborative (CCGC), a grant funded non-profit coalition of over 50 health care organizations, can provide practices seeking NCQA recognition with the onsite technical assistance ( IPIP) to enable practices to establish the systems and processes required to be NCQA recognized. CCGC Quality Improvement Coaches are also fluent in the integration of effective, low-cost software programs like Reach My Doctor that enable practices to deliver on the concepts of a Patient Centered Medical Home. Reach My Doctor has robust registry functionality in addition to HIPAA-compliant electronic communication to facilitate coordination of care between providers, and an excellent patient portal that engages patients in the management of their chronic conditions. CCGC coaching helps practices to develop effective processes and the necessary infrastructure to be able to provide planned care efficiently and effectively to manage chronic conditions and preventive medicine.
For medical homes to be successful broad changes will be necessary at the system level as well. Structuring compensation and incentive programs to cover the costs of the staff and electronic systems necessary to deliver medical home levels of care are necessary if medical homes are to remain economically viable. Barbara Starfield, author of The Primary Solution, argues that primary care in general, and primary care offices that adopt the concepts embodied in the Joint Principles in particular, not only improve patient outcomes but also significantly reduce health care costs, and the savings need to be redistributed to the people doing the work – primary care providers. Aligning financial incentives to recognize the value of care coordination and proactive care management is an essential component of making medical homes a sustainable model.
Selected for a multi-payer medical home pilot project, Colorado will have the opportunity to offer a small number of Colorado primary care practices the opportunity to test whether practices that achieve NCQA Medical Home Recognition and receive enhanced compensation will improve outcomes and reduce costs. As of this writing, six health plans have agreed to provide enhanced reimbursement to the participating practices. These health plans include Aetna, Anthem-Wellpoint, Cigna, Humana, Rocky Mountain Health Plans and United Healthcare. The actual project design is still a work in progress. CCGC has been designated as the convening organization to implement the multi-payer pilot in Colorado.
For more information about in-office coaching or the Reach My Doctor software to implement the medical home please refer to www.coloradoguidelines.org or contact Allyson Gottsman at 720-297-1681.
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