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Practices that aspire to become medical homes are required to set self-and evidence-based standards for access, communication and clinical care, create and document team-based strategies for achieving these standards, and document movement toward achieving standards.
The National Committee for Quality Assurance in 2008 published Standards and Guidelines for the Patient-Centered Medical Home (PCMH). The PCMH was created as a response to decreased interest in primary care as a career choice. Joint principles for the PCMH were created in collaboration with the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association.1
There are 10 must-past elements in the NCQA Patient-Centered Medical Home. These elements include developing and evaluating practice policies for access and communication, organizing clinical data, identifying three important medical conditions using evidence-based guidelines for these conditions, creating and evaluating patient self-management tools, empowering and effective use of office staff, follow-up and tracking of ordered tests and referrals, measuring clinician performance, and reporting aggregate and individual performance to physicians and other agencies.1
Practices that aspire to become medical homes are required to develop policies that comply with PCMH principles, set self- and evidence-based standards for access, communication and clinical care, create and document team-based strategies for achieving these standards, and document movement toward achieving standards. Most primary care physicians believe they incorporate many of these principles in their practice, but find they lack written policies, team-based strategies, and the means to document achievement. Some level of information technology is required to facilitate the documentation process. Electronic health records provide some help, but most lack disease registries and reporting systems that facilitate the needed documentation processes. Family medicine has several strengths that will aid in meeting the elements of the medical home, but most practices lack the resources to achieve many of the elements.2 Barriers include a lack of registries, evidence-based measuring tools, and processes to demonstrate quality improvement.
Another barrier to implementing the PCMH is a physician culture that does not value measurement. Physicians tend to reject efforts to measure their performance.3 They either reject efforts to be measured or, once measurements are available, seek to discredit the process or shift blame.
This attitude is a result of reports from managed-care companies that label physicians as "outliers" and a medical education system that does not incorporate measurement into outpatient care. Measurement or evaluation is viewed as a grade or an evaluation of worth. This barrier will only change if measurement is viewed as an initiation of the improvement process. This attitude and change of culture will depend upon the clinicians who lead the process within an individual practice. Their task is to help all members of the practice understand that the measurements are a reflection of their "system of care," not an evaluation of the care each one of them delivers. The next step is to "create new systems" to change the measurements. The speed of change will be slower for some than others, but with time and effective role modeling, an office can usually make the paradigm shift.
An additional barrier is the inability to work as a team. Physician training occurs mostly in the hospital, and the outpatient training they receive does not stress team care. Delegation of tasks to assistants in the outpatient setting is not modeled or encouraged. Team meetings may be held, but they do not model shared problem solving. Inadequate reimbursement has forced primary care practices to hire medical assistants (MA) rather than nurses to assist them in their office. MAs have limited training that decreases their ability to accept delegation. Physicians sometimes are able to train MAs, but effective training is not usually a skill physicians have been taught.
Office staff can perform several functions to increase the capacity of the clinician. These include functions that could easily be done by others, those that the clinician does not have the skills or time to do, and those that tradition has placed in the hands of the clinician but can be delegated to others. Team care improves health outcomes and reduces healthcare costs by increasing the number and quality of services that are provided. The clinicians are free to perform the tasks they are best suited to perform. The key is the clinician is the head of the team and is involved in the creation and management of the team.
In 2003, in response to a need to improve chronic disease care, the Florida Academy of Family Physicians Foundation created the Diabetes Master Clinician Program (DMCP).4,5 Diabetes was chosen because it is common, and excellent evidence exists that improvement in quality parameters decreases morbidity and mortality. The backbone of the program is the diabetes registry that serves as a means of documenting improved diabetes care. The registry currently contains over 16,000 patients and 50,000 visits. The program and registry is used by 80 practices, 200 clinicians, and 300 staff members.
Practices involved in the program first enter all their diabetic patients in an internet-based diabetes registry. Grant funds support data entry by a person independent from the practice. After data entry is complete, each practice participates in a training program. The training includes a discussion of the evidence-based standards of care for diabetes, dyslipidemia, and hypertension, followed by a review of data from their practice.6,7,8
Table 1 is an example of a report for a participating practice.
Patients Meeting American Diabetes Association Goals
HbA1c, LDL, BP
% That Met Goals
% That Met Goals
Clinic 80 Averages
# of Patients
# of Visits
BP (mm Hg)
Dilated Eye Exam
Once a year
Once a year
Total Cholesterol (mg/dL)
M:>40 F: >50
Once a year
Once a year
Before any data is presented, reaction to being measured is discussed, and physicians and staff are asked to suggest strategies for making system changes. They are encouraged to look for barriers and how to address them. Both physicians and nonphysicians are encouraged to answer, and nonphysician answers are supported. Many of the staff are asked for their opinions, and the meeting moderator encourages supportive staff participation. The NCQA PCMH requires that practices choose clinical conditions that have evidence-based standards, and that they document that the standards are being met. The report shown in Table 1 satisfies this requirement. Another report that helps improve diabetes care and that documents improvement are shown in Table 2.
Clinic number 80
Avg. >6.5 to <8%
Number of patients
Patient list of HbA1c from highest to lowest
# of tests
# of visits
This report also shows staff the number of patients at various risk levels with their HbA
values. Similar reports exist for low-density lipoprotein and blood pressure levels. Traditionally, medical care consists of face-to-face care for one patient at a time. Patients who are at risk but not in the office may fall through the cracks if mechanisms do not exist to identify them. The patients identified by these pracitice population reports usually have significant barriers that include cost, transportation, literacy, and lack of understanding of their disease. Strategies for discovering and addressing these barriers are discussed during the training process, and clinicians and staff are encouraged to meet periodically after the training to review the reports and develop solutions. Involving all staff members in solution development not only fulfills one of the NCQA PCMH criteria, but increases the chances that the solutions will be sustainable.
Table 3 shows another type of report that aids in population management. This report lists names of patients who have not had annual evaluations such as urine microalbumin or dilated eye exams, documented daily aspirin, and annual flu shots. (The patients listed in this report are fictitious.) The drop-down list notes patients who have not had an eye exam in the last 365 days. Clinicians and staff use this information to increase the number of patients who meet diabetes care standards.
List of patients who have not completed
an eye exam in last 365 days
Date of last exam
This report aids with the PCMH coordination requirement by noting who has not received an eye exam. Diabetic eye exams by an eye care professional require a consultation and communication with that professional. This report, as well as that in Table 4, aid with this process. If the exam is not performed or is not documented, a review of the reports increases the chances the exam will be performed.
Patient report card for Santa Claus
Age 63 Sex: Male Nonsmoker MR#1225
Less than 130/80
(sugar for 3 months)
Less than 7, best if 6
LDL (lousy cholesterol)
Less than 100, best if 70
HDL (happy cholesterol)
Greater than 40
(a bad fatty substance)
Less than 150
Aspirin (prevents heart attacks)
Important Yearly Activities
Next Test Due
Most Recent Test
Eye check (to prevent blindness)
1 time a year
(to check for sores and numbness)
1 time a year
(to check for kidney failure)
1 time a year
Flu shot (to prevent flu)
1 time a year
(to prevent special pneumonia)
Once in lifetime
2 times if first given before age 65
A report (Table 4) is also generated for patients (in language they can understand). This report is one of the most effective in the DMCP. It involves patients in their care, facilitates self-management, and informs them of their goals and the reasons for the goals. Patients are given this report by the nurse or MA who escorts them in the exam room. As part of the DMCP training, clinicians are encouraged to empower their nurse and/or MA to obtain needed annual tests, give immunizations, remind patients to take aspirin, and perform the monofilament foot exam. Some physicians are comfortable delegating these tasks, while others are not. Physicians who believe in team care and are willing to delegate have much better numbers than those who do not. Table 5 illustrates the changes that were made in one practice after the MAs were empowered to give the patients their report card and perform the needed tests and other activities. The PCMH requires involvement of patients in their care and has a provision that patient education materials that consider literacy. This report helps to fulfill that requirement.
Change in one practice over an 8 month period.
The DMCP program produces a cost savings by increasing the number of patients who achieve American Diabetes Association (ADA) quality goals. Bridges to Excellence commissioned an actuarial firm to analyze the cost savings attained when ADA quality goals are reached.9 Their analysis demonstrated a yearly cost savings for reaching goals in the following three indicators:
When these cost savings figures were applied to the 16,000 patients in the DMCP who had reached diabetes quality goals for the three indicators, the yearly cost savings for the DMCP was more than $2.7 million. One-third of the cost savings pertains to the patient (less absenteeism and increased productivity), and the remaining savings is for the direct cost of care.
Edward Shahady, MD, is the medical director of the Florida Academy of Family Physicians Foundation's Diabetes Master Clinician Program and a former president of the Society of Teachers of Family Medicine. Send your feedback firstname.lastname@example.org.
1. Standards and Guidelines for Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH), 2008 by the National Committee for Quality Assurance (NCQA).
2. Rogers J. The Patient-Centered Medical Home Movement-Promise and Peril for Family Medicine JABFM 2008;21:370-374.
3. Kenny ., The best practice: How the new quality movement is transforming medicine. Perseus Books Group, Philadelphia 2008.
4. Shahady EJ. Diabetes management: An approach that improves outcomes and reduces cost. Consultant 2008;48(4):331-339.
5. Shahady EJ. The Florida Diabetes Master Clinician Program: Facilitating increased quality and significant cost savings for diabetic patients. Clin Diabetes 2008;26:29-33.
6. American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 2008;30:S4-41S.
7. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003;289:2560–2571.
8. Grundy SM, Cleeman JI, Merz NB, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:2227–2239.
9. Bridges to Excellence website. http://www.bridgestoexcellence.org/assets/Documents/Program_Evaluation_Documents/DCL_analysis1207051.pdf accessed January 29, 2009.
MEDICAL ECONOMICS EXCLUSIVE:
Winner of the 2008 Award for Innovation in Practice Improvement, presented by the Society of Teachers of Family Medicine and Medical Economics