Medical Home
Core Features & Benefits | Talking Points | Coverage in the Media | Medical Home Initiatives & Projects | ResourcesA patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a personal physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience and optimal health throughout their lifetime.
Approved by the American Academy of Family Physicians board of directors on May 1, 2008
View Medical Home Video Introduction
View Medical Home Video, Part 2
Patient Centered Medical Home University Update
The Patient Centered Medical Home University (PCMH U) met in November for their fourth of five face-to-face meetings. TransforMED presented material on maintaining momentum as a learning organization, high performing teams, and care coordination-building collaborative relationships.
Linda Shelton, of Discern Consulting, the NCQA application specialist also presented to the group. She shared that 75 percent of the 26 practices enrolled in the PCMH U will be submitting their NCQA PCMH Recognition application before the end of the year. The majority of the others plan to submit their application in the first quarter of 2012. Nearly all are applying for the Level 3 (highest) recognition.
Different from previous meetings, there was a panel of current PCMH U members – thank you to Drs. Mitch Cook, Thad Riley, Michael Manning and Frank Don Diego! The panel discussion was noted by the attendees as the highlight of the meeting. Some of the comments from the panel include, "it (transformation process) was difficult at first, all change is, but it has been well worth it; our staff is engaged and excited; our efficiency has increased." Attendees' comments included, "these meetings have been very valuable; the experience of others is so helpful; it's good to know we're in the same boat."
Many of those in attendance found this meeting to be "the best yet!"
PCMH Update and Benchmark of Georgia Projects
As the GAFP's PCMH University project reaches the one-year mark, it's exciting to reflect on the progress of the project and look at other programs that have embarked on a similar journey. With the help of TransforMed and Discern, LLC, the 27 practices and residency programs that make up the PCMH University project have all forged ahead and are very close to NCQA application readiness. The clinical teams have attended workshops, conference calls, one-on-one consultations, and internal team meetings. All as part of the effort to ensure their practices are prepared to complete and submit the application for NCQA recognition as a patient-centered medical home by the end of 2011.
In addition to the PCMH University practices on the road to NCQA recognition, there are several other Georgia practices that are seeking to achieve PCMH status. When we look to the south of the State, we find the Savannah Primary Care Medical Home Project. According to the Patient Centered Primary Care Collaborative (PCPCC) website, the purpose of the Savannah project is to accelerate the adoption of the PCMH model of care in support of a larger community based health improvement initiative. They will monitor the impact on outcomes, quality, and cost for members in self-funded plans. Similar to the PCMH University project, they began with education and awareness, and expanded to assisting physicians with certification process. The projected reach of this project is 35 practices and 184 physicians.
Amerigroup recently launched a pilot project that focuses on transforming their delivery system and working more directly with providers of health care services to improve the quality and efficiency of the care delivered to Amerigroup members. The core of their strategy is focused on devoting resources to primary care providers to assist them in becoming highly functioning patient-centered medical homes within an integrated delivery system. The Amerigroup project hopes to reach 29 practices and 347 physicians.
The CIGNA/Piedmont Physician Group Collaborative Accountable Patient Centered Medical Home project is designed to use patient level actionable data and trend data to support practice actions with the goals of improving quality of care, affordability of care and satisfaction. Although the focus of this project is on pediatric practices, this collaboration enables the clinical team to identify gaps in care and improve the quality of patient care. This project will target 4 practices and up to 93 physicians.
As noted with the increase in PCMH projects throughout the State and beyond, it is fair to say that becoming a patient-centered medical home is top priority for many organizations who strive for quality improvement and excellence in patient care.
PCMH University Practices Begin NCQA Application Process
The Patient Centered Medical Home (PCMH) University met for their third workshop on August 5-6. These face-to-face workshops are valuable in supporting the members– as they transform their practice to meet standards that will lead them to NCQA recognition as a PCMH.
During the August meeting, NCQA application specialist Linda Shelton met with each practice to review their practice specific survey tool. The NCQA applications from PCMH U's first class will be submitted this December. GAFP is excited as this first class steps closer to the goal of NCQA PCMH recognition!
NCQA Releases 2011 PCMH Standards: The Good, the Bad and the Ugly
by Leah Newkirk, California Academy of Family Physicians
The National Committee for Quality Assurance (NCQA) released its 2011 Standards and Guidelines for the Patient-Centered Medical Home (PCMH) in late January. In many ways, these revised standards represent an improvement: they are better organized, easier to understand and more streamlined. The NCQA, responding to the comments of stakeholders like the AAFP, has placed greater emphasis on the patient experience and quality improvement and measurement. Perhaps most significantly, there is a new alignment with the concept of "Meaningful Use." NCQA has recognized the indissoluble connection between PCMH and Health Information Technology (HIT).
Six main 2011 standards, compared to nine 2008 standards, demonstrate an effort to simplify the evaluation process.
The Standards: Now and Then
2011
- Enhance Access and Continuity
- Identify and Manage Patient Populations
- Plan and Manage Care
- Provide Self-Care and Community Support
- Track and Coordinate Care
- Measure and Improve Performance
2008
- Access and Communication
- Patient Tracking and Registry Functions
- Care Management
- Patient Self-Management Support
- Electronic Prescribing
- Test Tracking
- Referral Tracking
- Performance Reporting and Improvement
- Advanced Electronic Communications
Example: Standard 1. Enhance Access and Continuity (20 Points) Element A. Access During Office Hours (4 Points)
Evaluation: The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for:
- Providing same-day appointments;
- Providing timely clinical advice by telephone during office hours;
- Providing timely clinical advise by secure electronic messages during office hours;
- Documenting clinical advice in the medical record.
- Level 1: 35-59 points and all six must-pass elements
- Level 2: 50-84 points and all six must-pass elements
- Level 3: 85-100 points and all six must-pass elements
Prominence of Patients
The 2011 standards direct practices to organize care according to patients' preferences and needs. The standards emphasize collaborating with patients and their families in the delivery of care and increasing access to care during and after office hours. The standards reward practices that provide services in patients' preferred languages, support patient self-care and integrate community resources. There is a focus on integrating behavioral health care and care management. Additionally, patients and their families are involved in quality improvement.
Beginning in January 2012, NCQA will offer additional points based on reporting results from a standardized patient experience survey. Practices will be invited to use the Medical Home version of the Consumer Assessment of Healthcare Providers and Systems Survey (currently in development and sponsored by the Agency for Healthcare Quality and Research in collaboration with NCQA). Practices can earn NCQA Distinction for collecting data using the survey and reporting the results to NCQA.
HIT: Integral to PCMH
Another highlight of the new standards is their alignment with the federal electronic health record (EHR) incentive programs. Meaningful Use language is embedded in the 2011 standards, encouraging practices to adopt EHRs. For example, in the area of enhancing access and continuity, the standards look at whether patients have electronic access to their current health information (such as lab results or medication lists) and can request electronic copies of their information. For identifying and managing patient populations, the standards evaluate whether practices are using electronic systems to record areas such as allergies, blood pressure and prescription medications.
While the new program aligns closely with the incentive programs, NCQA recognition and Meaningful Use are not synonymous; family physicians need not achieve Meaningful Use to be an NCQA-accredited PCMH and vice versa. Rather, there is significant overlap.
Departure from the Joint Principles
One criticism of the 2011 standards is their departure from the Joint Principles of the PCMH developed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. The NCQA dropped the requirement for attestation to the Joint Principles and has moved away from the principle of physician-directed PCMH. NCQA has dropped "Physicians Practice Connections" from the title of the accreditation program and refers to clinicians, rather than physicians, throughout. Non-physicians "primary care clinicians" can qualify for NCQA accreditation.
Take Home Message
NCQA is perhaps the most prominent of those developing standards for PCMH. Almost 7,700 clinicians at more than 1,500 sites across the United States have used earlier NCQA standards to received recognition as a PCMH. The NCQA should be lauded for the dissemination of the PCMH model that will undoubtedly result in improved quality, increased access and decreased costs.
NCQA did an admirable job of incorporating patient-centeredness and HIT. The NCQA made an effort to streamline its evaluation process and has certainly moved in the right direction. The organization failed, however, to preserve its connection to the Joint Principles, a regrettable departure from the perspectives of family physicians.
The PCMH standards are available on the NCQA Web site (www.ncqa.org) at no cost and practices can call NCQA at 888-275-7585 for more information.
GAFP Continues Medical Home Initiative
Since launching the 2010 partnership with TransforMED entitled the Patient Centered Medical Home (PCMH) University, the Georgia Academy successfully conducted its first workshop in November with the 27 practices signed on to take part in the initiative. In February, GAFP leaders and TransforMed partners presented the PCMH model to insurers to introduce them to the PCMH University project and discuss the benefits of a PCMH to the patient, the physician, and the payer.
This June at GAFP's 2011 Summer Family Medicine Weekend CME meeting, GAFP will offer the 2nd PCMH University workshop to participants with a signed letter of agreement on file. For GAFP members who are not signed on to the PCMH University project, there will be an educational lecture during the meeting that will highlight the importance of being a PCMH recognized practice and offer insight into becoming a PCMH. Dr. Wayne Hoffman, GAFP Board Secretary and former insurance company executive will offer information on the importance of the patient centered medical home, outline the difference between a traditional versus a PCMH practice, and illustrate current outcomes and findings related to creating a framework for change within your practice.
Dr. Hoffman's presentation will show how PCMH practices have reduced ER visits by 4.5%, improved practice revenue by 11% (on average) over a two-year period, and increased their implementation of preventive health measures by 40%.
For additional information on the 2011 Summer CME meeting, contact Angela Flanigan, GAFP Director of Education at 800-392-3841 or aflanigan@gafp.org.
GAFP Leadership & TransforMED Visit with Insurance Payers
The Georgia Academy of Family Physicians, in partnership with TransforMED, launched the Patient Centered Medical Home University on November 13, 2010. It is a two year process that will assist GAFP members in achieving NCQA recognition for being a Patient Centered Medical Home (PCMH).
This February GAFP President, Dr. Harry Strothers, III; Secretary, Dr. Wayne Hoffman; and GAFP Executive Vice President Fay Brown along with TransforMED leaders, Dr. Terry McGeeney and Dan Mckean, presented the Patient Centered Medical Home model to WellCare, AMERIGROUP, Peach State, United Healthcare, Coventry, and Blue Cross/Blue Shield of Georgia.
The objective of these meetings was to introduce the insurers to the PCMH University project and discuss the benefits of a PCMH to the patient, the physician, and the payer. In a demonstration project similar to the PCMH University organized by TransforMED, the two year outcomes data revealed improved practice revenue, improved physician salaries, improved efficiencies and quality, and improved provider and staff satisfaction. This data certainly reflects a win-win situation for those with a functioning patient centered medical home.
The PCMH University has a total of 27 practices that are part of this initiative - 22 of these practices are family medicine, one is an internal medicine practice, and three are family medicine residency programs. The outreach in Georgia of these 27 include the cities of Ocilla, Athens, Statesboro, Rome, Thomasville, Dawsonville, Conyers, Duluth, Thomason, Oakwood, Lawrenceville, East Point, and Atlanta.
For additional information on the PCMH University, contact Cathi Durham, GAFP Director of Outreach at 800-392-3841 or cdurham@gafp.org.
Patient Centered Medical Home University Launched!
The Georgia Academy of Family Physicians, in partnership with TransforMED, has launched the Patient Centered Medical Home University! The invitation was open to family physicians, pediatricians, and internal medicine physicians and was well received. The first meeting of the PCMH-U was held November 13 at the GAFP Annual Meeting with physicians and their staff attending - there were a total 68 participants in this enthusiastic group. There are 22 family medicine practices, two internal medicine practices and three family medicine residency programs that have signed on to take part in the project. The outreach in Georgia of these first 27 includes the cities of Ocilla, Athens, Statesboro, Rome, Kennesaw, Conyers, Duluth, Thomason, Lawrenceville, Brooklet, Cairo, Sandy Springs, Marietta, Riverdale, and Atlanta.
For information regarding the PCMH University contact Cathi Durham at 800-392-3841 or cdurham@gafp.org
Patient Centered Medical Home - Value for Many
The GAFP and the Georgia Division of Public Health understand the value of medical homes and their positive outcomes. Recently, GAFP endorsed a new brochure created by Public Health which informs parents and non-healthcare professionals about the importance of a medical home. Brochures will soon be available for distribution.
Over this past summer, GAFP announced a two year project that will assist family physicians in Georgia to achieve NCQA recognition as a Patient Centered Medical Home (PCMH) at a deeply discounted rate. This project, PCMH University, will include face-to-face meetings with TransforMED five times over the next two years and will work with practices in a virtual format the rest of the time.
On August 31 a webinar outlined the details of this exciting project. You can view this webinar at: https://transformed.ilinc.com/join/brhmstr
Only 9 slots remain to participate in this amazing program. If you are interested in learning more, do not delay; contact Cathi Durham at cdurham@gafp.org or (800) 392-3841.
Patient Centered Medical Home in Georgia
Currently the Center for Primary Care in Augusta and the Harbin Clinic in Rome are recognized by the National Committee for Quality Assurance (NCQA) as a patient centered medical home (PCMH). The larger of the two is the Center for Primary Care in Augusta and most of the partners at this practice are GAFP members.
GAFP is excited to announce a partnership with TransforMED, a subsidiary of the AAFP, to assist family physicians in achieving PCMH recognition. Pediatricians, Internal Medicine physicians, and DOs will also be able to participate. This two year project will involve 15 to 30 primary care practices in Georgia. To learn more, join us on a webinar, August 31, at 1:00 pm. To register go to https://transformed.ilinc.com/register/wkprzzx
NCQA defines a patient centered medical home as "a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate the patient's family. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner." The program standards are available from NCQA at no cost, at http://www.ncqa.org/tabid/629/Default.aspx#pcmh
TransforMED offers many resources for transforming your practice into a patient centered medical home, including a baseline practice assessment. For access to these resources and additional PCMH information, visit their website at http://www.transformed.com/
GAFP Surveys Members on the Patient Centered Medical Home
How ready are we to become a Patient Centered Medical Home (PCMH)? The Georgia Academy of Family Physicians surveyed members in March to gauge how ready you are in achieving this goal.
Over 1,500 active members of the GAFP were contacted to participate and 212 completed the survey.. When asked how familiar the participants are with the AAFP's PCMH initiative, 59 percent were aware of the criteria, but not how to implement, and 19 percent had never heard of the initiative. Fifty-one percent believe it to be a viable model, yet only 10 percent have taken the AAFP TransforMED Medical Home IQ Assessment. Fifty-four percent of the participants are interested in receiving the National Committee for Quality Assurance (NCQA) designation as a PCMH; one participant has achieved this title. Fifty-one percent of the participants use a fully implemented Electronic Health Record (a requirement to become a PCMH.)
The two biggest obstacles in implementing the PCMH model were financial investment and time. Many members commented that not only is the financial investment a barrier, but also the lack of known reimbursement once a practice has attained the designation of PCMH. When asked what financial incentives would be of interest, the number one answer was funding for start-up costs, followed closely by a per member, per month care management payment.
The participants were asked what tools, training, or services could GAFP provide to help transition their practice into becoming a qualified PCMH; the top answers were CME education, an all day workshop for office staff, and networking with successful PCMH practices. Other needs included education of support staff and providers, 'start up' support for locating or developing appropriate tools for working and communicating with patients about the process, and technical support in practice transformation facilitation.
For additional information, contact Cathi Durham, Director of Outreach at (800) 392-3841 or cdurham@gafp.org.
GAFP and TransforMED have a working relationship in which members receive a discount on the road to becoming a PCMH. To learn about TransforMED and their new Small Practice Package, visit http://www.transformed.com.