Becoming a PCMH is more than just a change in the way a practice is reimbursed. It is a change in the medical culture.
Many physicians agree with the idea of transforming their practices into patient-centered medical homes (PCMHs), where care coordination optimizes patient engagement and satisfaction. However, shifting from the standard practice model to one based on value and patient service is difficult while also operating a practice.
Nearly 7,000 primary care practices are accredited as PCMHs, according to the Accreditation Association for Ambulatory Health Care (AAAHC), one of several organizations that offer practices assistance in the PCMH process. But becoming a PCMH is more than just a change in the way a practice is reimbursed; it is a change in the medical culture.
“The hardest part was convincing primary care providers to buy into the program,” said David T. Tayloe Jr., MD, FAAP, of Goldsboro Pediatrics, Goldsboro, North Carolina, in a white paper released by AAAHC in October 2014. “It is easy for providers who are paid fee-for-service to ignore the medical home agenda that entails care coordination and integration of care into the health, human services and education sectors of the community.”
And there are still a lot of detractors who say PCMHs have failed to improve patient outcomes and efficiency. A RAND study in 2014 found that one of the first and largest PCMHs, the Southeastern Pennsylvania Chronic Care Initiative, showed improvements in only one of 11 quality measurements, compared with other primary care practices.
“Several obstacles exist in achieving successful medical homes, and challenges have certainly fueled criticism,” says Jack Egnatinsky, MD, medical director for AAAHC and author of the white paper. “What we are witnessing today, however, is a growing body of evidence that, when viewed collectively, presents an overwhelming stamp of approval on the medical home model.”
Taking a strategic approach to becoming a PCMH may be helpful, but it is also important to consider the financial, philosophical and technological commitments that must be undertaken.
Transforming a practice into a PCMH is a process that requires a change in practice philosophy, as well as care coordination accreditation, that can take years.
“In the current landscape, after nearly three to four years of transforming, many of the practices are only part-way there,” says David Nace, MD, vice president and medical director for McKesson Health Solutions. “For one, our current medical system is not designed to take care of populations, nor has it been historically financed or incented to provide holistic ‘whole person’ coordinated care.”
MORE COVERAGE: Six ways to get started on a PCMH
Even after a practice is accredited, the changing reimbursement landscape is not equipped to pay for value-based services. The recent addition of chronic care and transitional care management codes in the Medicare Physician Fee Schedule is a promising step in promoting the PCMH approach to care delivery.
But even after accreditation by organizations such as AAAHC, the National Committee for Quality Assurance, the URAC or the Joint Commission, the definition of a PCMH is always changing.
“In many ways one never ‘becomes’ a PCMH; it is an ongoing focus on continuous improvement-not just from a quality standpoint but from one of healthcare stewardship-understanding that healthcare resources are precious and need to be managed,” Nace says.
Technology is an essential part of the PCMH equation.
The U.S. Department of Health and Human Services Health Resources and Services Administration suggests that practices considering the PCMH approach have some or all of the technology components below:
However, many practices owners find that the promises of the PCMH outpace technological capabilities.
"Forming our teams, increasing patient communication and doing care coordination were not difficult… (but) our information systems lag behind our work processes,” says Joseph E. Scherger, MD, vice president, primary care for Eisenhower Argyros Health Center in La Quinta, California and a Medical Economics editorial board member.
Also, in order for these technologies to be effective, the relationship between patients and their care teams has to be strong.
“The use of tools like texting, mobile applications, secure messaging, portal access to medical information, satisfaction and quality improvement surveys are fine to start with, but to move to a truly engaged population with high levels of service, one needs to change the relationship between the practice and patients, which requires time and focus,” Nace says.
The best way to know what patients want is to ask them-and with demands coming from the government and payers, sometimes practitioners forget this fact. Some PCMHs have patient advisory boards that include not just patients, but their caregivers and family members.
“Patients, families, and caregivers can share their perspective as consumers of the practice and provide helpful insight. Some practices convene patient advisory committees to work on targeted improvement strategies,” Nace says. “With their deeply personal knowledge of how to manage a chronic condition, patient partners can help practices understand the barriers patients and caregivers experience accessing the health care system and managing health challenges at home.”
Ultimately, educating patients and other healthcare stakeholders will help care coordination continue when a patient leaves the doctor’s office.
“A final challenge is the need to design care systems that encourage more participation by patients in their own care,” says Nace. “This can include better access to information on cost and quality among providers and healthcare systems, better decision aids that can be customized for patients based on clinical profile, culture and beliefs, and more involvement of patients in designing the systems of care.”
One simple way to begin incorporating the PCMH way of thinking is to look at current practice processes and assess their efficiencies.
“Patient engagement also transcends the treatment cycle. Recent studies have also shown that a patient’s overall satisfaction is increasingly tied to satisfaction with the financial experience,” says Nace. “There are technologies in use today that help prevent downstream denials, accelerate overall care decisions through administrative care coordination, and increase patient satisfaction by ensuring quick administrative and payer decision resolution.”
According to the National Committee for Quality Assurance, 20% to 50% of referring physicians don’t know what specialist their patients are going to, and if they go to follow- up appointments. Developing a system for tracking patient referrals is one way to wrangle care coordination.
In addition, evaluating the waiting room, how long patients wait exam rooms, and how they interface with staff can enhance the patient-centered experience.
A review of the key principles applied by the Accreditation Association for Ambulatory Health Care in this process:
Here are four ways your practice can move towards the PCMH model and improve care transitions for your patients:
Review operating principles
Practices seeking PCMH certification must change their operations to fit with the Patient Centered Primary Care Collaborative’s Joint Principles of the PCMH. That includes rules for patient relationships with physicians, care coordination, and exchange of health records. An electronic health record system is vital. More information can be found at: www.pcpcc.net/joint-principles
Select a care coordinator
A PCMH requires a patient care coordinator to oversee the process, someone who is computer-savvy and empathetic. It’s about population management.
Consider seeking recognition
Although an official stamp of approval isn’t required for practices to brand themselves as PCMHs, formal recognition has many benefits. For example, most medical homes recognized by the National Committee for Quality Assurance receive financial rewards from Medicaid or private payers.
Communicate with patients
Practices should reach out to patients when they begin their PCMH transformation. Patient engagement is critical to the success of the venture. Consider including patients in your redesign plans, because their insights can help you evaluate workflow and improve the patient experience.