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How to coordinate care in a medical home


Becoming a Patient-Centered Medical Home isn’t as simple as marking a few items off a checklist and incorporating them into a traditional practice. The transition usually involves a culture change within the practice and buy-in from the care delivery team to improve efficiency and patient health. Here's what you need to do.


Becoming a Patient-Centered Medical Home (PCMH) isn’t as simple as marking a few items off a checklist and incorporating them into a traditional practice. The transition usually involves a culture change within the practice and buy-in from the care delivery team to improve efficiency and patient health.

Although the benefits of becoming a PCMH-better outcomes, greater efficiencies and improved care coordination-have been well-documented, it is still difficult for many physicians to make the transition. This article explores some of the most important considerations for physicians in office-based practices and outlines the steps necessary in becoming a PCMH.

The first step in creating a practice focused on care coordination, says Bruce Bagley, MD, FAAFP, interim president and chief executive officer of TransforMed, is to identify the patient population within your practice most in need of this kind of care. Ultimately, you are creating a system to coordinate care for all patients-touching base with their specialists, getting copies of lab results, and following up on any treatment plans. To start, identify those patients with multiple referrals or hospital admissions.

Once you have identified this population, you will need to carefully consider a myriad of organizational questions and financial realities, including staff costs, time, software, and reimbursement. What system is in place to track all those patients, how will you pay for the software that best enables data collection and tracking and appoint an employee within your practice to facilitate patient care coordination

1. Decide whether you can afford the price

Offering your patients intimate, personalized care; coordinating their care with other providers; and improving their access to your services comes with a price. Costs are involved with implementing a PCMH and achieving the certification necessary to even begin thinking about leveraging PCMH status for increased reimbursements.

Salvatore Volpe, MD, FAAP, FACP, CHCQM, owns a small practice in Staten Island, New York. An early adopter of the PCMH model, Volpe says he first pursued recognition as a medical home in 2008, although he always believed his practice to be one.

“I knew I wanted to continue doing what I did,” says Volpe, a member of the Medical Economics Editorial Board. “I think I’ve always practiced a PCMH. It was Marcus Welby, a Normal Rockwell practice. The ideal is there.”

But back in 2008, and even now, Volpe says, increased reimbursements merely for achieving PCMH certification can be difficult to come by. Enhanced reimbursement is available, but it’s difficult to find initially, he adds.

“You don’t want to do all this work-[especially if] you’re an independent practice-and not get paid for it,” adds Joseph Scherger, MD, MPH, also a member of the Medical Economics Editorial Board. Scherger is vice president of primary care and academic affairs at Eisenhower Medical Center in La Quinta, California.

Physicians need to be certain their finances can handle the transition to a PCMH before embarking on the journey, he says. That’s because payment to cover care coordination is included as part of a PCMH’s increased reimbursement, and from meeting quality metrics, rather than being billed under a specific code.

“You’re not going to want to do something that takes more work and money unless there’s a financial benefit,” Scherger says.

In his community, Volpe says, increased reimbursements from payers for becoming a PCMH is more the exception than the rule, but it’s different in other parts of the country. Some payers will provide grants or financial assistance for a practice to participate in a pilot program-an opportunity that Volpe says was available in his area.

“For the past 25 years, we have tried to do the right thing, even though there was little or no reimbursement for the time and effort,” he says.

But physicians simply cannot depend on payers closing the income gap that can result after becoming a PCMH, Volpe says. He knew that he would have no significant reimbursements for his PCMH implementation costs and that it would cost him $50,000 to $75,000 to run his PCMH in terms of lost opportunities.

“If I could see 25 patients in an 8-hour day before becoming a medical home, I would probably only be able to see 15 patients in a day as a medical home,” Volpe says.

Much of the burden in running a small practice as a medical home falls on the shoulders of the individual physician or physicians. You may not be able to afford to staff a care coordinator or more nursing staff, so if you are spending more time talking with patients and coordinating care, it obviously will mean that the volume of patients you are able to see will decrease, he explains.

Looking at patients metaphorically as an iceburg, Volpe explains that the current model of care only allows physicians to treat what is at the tip of the iceburg and get paid for that service. But as a medical home, Volpe says, he spends part of his time in the exam room treating the issue that brought the patient into his office and the remainder of the time talking about anything and everything else-what specialists he or she has seen since the last visit, how the family is at home, what is going on in his or her personal life, and how it is affecting the patient’s health.

“That solidified the PCMH. It’s what we want to take care of,” Volpe says before returning to his iceburg analogy. “Most healthcare just deals with the little tip that’s above the water. It doesn’t give you a lot of opportunity to address all the health issues that patient might have. The only way to look under that water line is to give [the patient] time.”

Although time is what will cost a physician most in missed opportunity with other patients, it also will provide room for possible bonuses. Volpe says that some payers are now offering reimbursement to cover additional communications with patients, such as secure emails and private patient portals. Some providers even charge fees for access to patient portals outside the exam room.

“That covers this missed opportunity cost,” Volpe says.

Other options to offset the  costs of running a PCMH include tapping into different payers or state and regional medical societies, getting involved in pilot programs, or finding side work-Volpe says his consulting work has been helpful in cushioning his “missed opportunities.”

“I was willing to provide the best care I could, and I’m lucky enough to get consulting jobs, so that absorbs some of that $50,000 to $75,000 loss,” Volpe says. “[But] if you can’t absorb loss by providing more intensive care, then you can’t afford it. If you willing to absorb it as a loss in income, that’s a business decision. If you’re lucky enough to have payers reimburse you better, that’s the best way.”

2. Make a plan, and engage your staff

Once you’re made the decision that your practice is ready and able to transition to a PCMH, Volpe recommends reviewing the many avenues to certification and choosing one. Several free resources are available, and Volpe recommends going through the National Committee for Quality Assurance (NCQA), a private, not-for-profit organization that offers guides and accreditation resources based on where you are in the transition process. The organization’s Web site,, he says, is helpful-even more so than when he started in the process.

“They’ve recognized that there are certain people who were willing to be early adopters and do more on their own, but to become more of the norm, they need more tools out there. And they have a lot of great free tools,” Volpe says, adding that physicians can request a free copy of the standards and guidelines for becoming a certified PCMH as an early step to crafting their plan to become a medical home.

Once you’ve found some resources and started a plan, make sure your staff knows what’s going on and is supportive of the practice’s new direction, Volpe says.

“Make sure you have buy-in from your staff,” he says. “It will require some refinement in how the practice operates.”

“Leadership is key,” Bagley says. “It’s getting everyone to do something they normally wouldn’t do on their own. If you have someone who’s leading the effort to motivate everyone’s hearts and minds to get them to work differently…that certainly is a key ingredient.”

Scherger emphasizes to his staff the importance of being pro-active in managing conditions, especially diabetes and other chronic diseases.

“The traditional practice is about reacting to the needs of the patients who come in that day,” he adds. “Under the PCMH, we reach out to the patient. ‘Your last lab results were out of control. Are you taking your meds?’ That’s the approach we emphasize to our staff,” he says. 

Regional extension centers associated with the Office of the National Coordinator for Health Information Technology can provide additional assistance, Volpe says. Originally set up to provide support for meaningful use requirements, the agency’s goals overlap much with PCMH initiatives. They both support new ways to collect information, offering data transparency for patients, and the idea that the patient and physician need to work as a team.

As you increase connectivity between the patient and the provider and attest to meaningful use, you are already about one-third of the way toward achieving PCMH status, Volpe says.

3. Check your information systems, and assign a care coordinator

“You can’t start at all until you’ve got an information system that allows you to look at your population,” Scherger says. “It isn’t just paper charts on a wall and you’re taking care of patients one at a time. You have to be able to pull up who your diabetic patients are. Who are your patients with high blood pressure? You need to be able to begin to look at your practice as a population.”

One of the real “scandals” of electronic health records (EHR) systems has been the lack of registry functions, Scherger says. Early EHR systems didn’t have any way to search a patient database for population information. Now, that capability finally is being added.

“You’ve got to make sure that your EHR has registry function that lets you do population management,” Scherger says. “If you don’t, it needs to be upgraded or changed or you can’t be a PCMH.”

Sometimes, practices will have to buy an add-on, but Scherger says it’s imperative to be able to capture all your core criteria. The registry doesn’t even need to be in your EHR system, he adds. Freestanding registry systems are available, he adds, reiterating that the key is getting a system and a mindset that gets you to think about your practice in terms of population management. The continuous, coordinated care at the center of the PCMH philosophy depends on being able to see where your patients have been and where they are now. (For more information on stand-alone registries as well as those that are part of EHRs, see the article that begins on page 58.)

A good registry should have five key functions, Bagley adds:

  • It has to be able to create a list of all your patients with a specific condition.

  • It has to be able to generate a status report for each of those patients outlining what parameters are in range so you can quickly assess where there are gaps in care.

  • It should be able to aggregate all the patients within the practice who have that condition so you can begin to offer population-based care to the group.

  • It should support outreach efforts. Once a population is identified, the registry should be able to easily provide phone numbers or other ways to get in touch with those patients for additional follow-up or appointment scheduling.

  • It should include a function to report quality measures for PCMH certification purposes.

This all takes time and work, Bagley says, and many practices appoint a care coordinator.

“Care coordination can vary with the acuity of the patient mix,” says Volpe. “For us it can run from 10% to as much as 30% of the work week.

Designating a staff member as a care coordinator is ideal, Scherger says. In his practice each physican is assigned a care doordinator, who spends 1 to 2 hours per day performingcoordination-related tasks.“ A larger practice could have a full-time nurse doing it 40 hours per week,” he says.

Contrary to popular belief, Bagley says, the care coordination doesn’t necessarily need to be a full-time employee. In small practices especially, he says physicians should select one loyal staff member and obtain for him or her the training needed to perform the care coordination functions.

But your practice needs someone to coordinate care on a daily basis, making sure referrals happen, ensuring that the right lab work is being done, making sure that diabetic patients are getting in on time and that they are seeing their other specialists. Practices operating this way are able to offer care proactively.

“Medicine traditionally is visit-based and is almost 100% reactive,” Scherger says, adding it helps to have an information system that can tell you how you’re doing and a care coordinator to reach out to patients and get them in for care that allows the physician to become strategically proactive with their care coordination. “That makes a huge difference.”

For example, a good information system will deliver to the practice data on how many women aged more than 50 years the practice cares for and how many haven’t had a mammogram in the past 2 years. A care coordinator then could call and schedule a mammogram for those patients who are in need, Scherger says. In a PCMH, more than half of patients in a subgroup should be getting the recommended care-and up to 85% in an advanced PCMH.

The care coordinator also will track referrals. He or she should be aware of all referrals being made from the practice, Scherger says. Every medical assistant (MA) should be performing that task, too, and information systems should back up staff efforts.

A good medical home practice refers a patient, then sends the specialist a summary of the patient’s medical records. The primary care physician then should receive information back from the referral source or should request it if needed, and review those data before the patients’ next visit.

“You go beyond the days where you’re seeing a patient without the information you need,” Scherger says.

But to achieve this system of care, Scherger says, practices will need to operate more efficiently and make better use of their resources.

“You need to begin to assign to your staff everything they can do within their license,” he adds. In a traditional practice, the doctor does everything and everyone else is ancillary. In a medical home, the delivery of healthcare is now a team activity where MAs have been trained to know what patients need.

“Make sure your staff comes to work every day not just wondering what their schedule looks like but how they will make population healthier,” Scherger says.

4. Engage patients to become partners

The public didn’t warm up to online banking, booking their own travel, or other self-service initiatives overnight, and their traditionally passive role in their own healthcare will take some time to change. But Scherger says that giving patients more access and power will help them take control and become more actively engaged in their healthcare decisions.

The goal of the PCMH is informed and activated patients, he says. When they know what they’re supposed to do and can access their records more easily, they can take more ownership of the process. At Kaiser, Scherger says, patients order all of their own medical tests-under the observation of their healthcare team, of course. The system has reduced patient visits by 25% by letting patients do more online. Although decreased visits may seem counterproductive, Scherger says the case is actually the opposite.

“In many offices, doctors wish they had more time with the patients who really need to be there,” he says. “If you can offer continuous access online to some patients, you can reserve office time for the patients who need it more.”

Online platforms help increase patient engagement, as do group visits that focus on particular subgroups. Gather all of the diabetic patients together to discuss their care and what the medical home can do for them; let them know you want to be as helpful as possible, Scherger says. Patients will begin to ask more questions, and you can urge them to keep their own calendars of the things they need to do.

“Get away from the paternalism, and put the responsibility on the patient,” he says. “Patients have not had any power or ability. I think that’s why they’ve stayed relatively passive.”

Secure patient portals create an entire new dynamic with patients and increase efficiencies within the practice by allowing staff to handle simpler matters in less time.

For example, a recent study found that out of 2,000 patients, roughly 50 need something from the office on a given day, Scherger says. A visit will take about 20 minutes of a physician’s time, and patient requests and questions by phone require an average of 7 to 8 minutes of synchronous communication. But what if you could handle 20 or 30 of your daily requests at your mutual convenience online? The average time to process an online request is about a minute, Scherger says.

“You can re-engineer your practice to care for more people in less time through efficiency,” he says. “Continuous care means taking your demand and handling it way more efficiently.”

More changes to come

For those about to go down the PCMH path  or thinking about it, Volpe says it will get easier.

Increasingly, EHR companies are realizing that a lack of searchable data is a barrier to many practices. This functionality has to make it easier for physicians to provide evidence for the organizations that provide recognition, Volpe says. Indeally, physicians could add data into their EHR systems and have a report created for recognition agencies within the scope of the patient visit.

EHRs also could help identify better reimbursement models in the future, Volpe says. For example, he adds, his EHR service is now offering to meet virtually with practices and look at what kinds of additional reimbursements are available in their areas in terms of meaningful use money and grants. For a fee, it will provide a physician with the reporting tools to help apply for those grants.

Headway already is being made in terms of the time it takes to satisfy the requirements to become certified as a medical home, Volpe says.

“It took me a whole year to attest for 2008, in terms of getting all the evidence,” he says. “Every weekend, my office manager and I would go through the electronic records and say, ‘How do we prove to NCQA how we did this?’ For 2011, the EHR was a little bit more mature, and there were more and more reports we could press a button and generate, but there was still a certain amount of manual data extraction that had to be one. Newer EHRs are making it easier for doctors.”

EHR vendors may make you pay for newer modules that help you extract the data you need, but the cost is relative, Volpe says. If it takes a physician 50 hours to compile the data, considering the value of his or her time and the cost of the program, Volpe says, he would gladly pay the money up front.

“If I could be spending time with my family, why would I want to be making a spreadsheet?” he asks.

Scherger adds that although physicians may worry about how to pay for the PCMH transition now, that won’t be as much of a concern in the future.

“Everything is moving toward quality being the new finance,” he says. “The real imperative to invest in the medical home is the understanding that you’ll be paid more for the quality of care you’re delivering to the population you’re taking care of rather than just treating them.”

Volpe estimates that the likelihood of enhanced reimbursement for PCMH status will continue to increase over the next year. PCMH status will become a marketing tool, and patients will begin to decide whether to keep their physician or find a new one based on how well they are cared for in the future, he says.

“The next thing in primary care will be patients asking, ‘Is he a PCMH Level 3?’ To be book smart and not provide the services some people want is not enough,” Volpe says. “Just provide the extra time to better help patients help themselves. You patients will appreciate it better, and you’re more likely to hold on to patients if you do it.”


Critical steps along the way to PCMH care coordination

Costs, engagement of staff and patients, and certification requirements all important as you change your practice

Step 1: Identify costs of implementation within your practice.

Do you have an electronic health record (EHR) system? Does it include a registry function? If you must purchase a registry system, how much will an interface with your EHR system cost? Do you have an existing employee to appoint as a care coordinator for the practice, or do you have to hire one? After identifying these costs, decide whether your practice can absorb those additional costs or whether you need to seek out grants, become part of a pilot program, or negotiate higher payments from payers.

Step 2: Engage staff.

Becoming a Patient-Centered Medical Home (PCMH) isn’t all about costly new technology systems. It’s about transforming the way your practice operates from treating patients individually to treating them by population groups and coordinating their care-even the care they receive outside your practice. A PCMH also relies on the idea that the practice is more than just the physician. Some clinical duties and much of the care coordination work can and should be delegated to other members of the practice team. Becoming a PCMH is a cultural change, experts say, and it requires strong leadership and staff buy-in if it is  going to work.

Step 3: Set up information technology systems to allow for better care coordination.

An ideal system will track patients with specific conditions by population group and provide the practice with data about their baselines and what specialists they are seeing, facilitate communication with those specialists, track necessary services and what appointments are needed, and allow someone within the practice to contact the patient for scheduling. Making sure care of each patient within a population is coordinated across each of their providers is a key element to becoming a PCMH.

Step 4: Engage patients, and make them a part of the process.

Many PCMHs have found success in engaging patients in the care process by creating personalized resources, online portals, and support groups. Giving patients greater access to their health records and bringing them into the process will help them to become more actively engaged in the process, thereby creating a two-way dialogue between the healthcare provider and the patient.

Step 5: Know the requirements for certification, and seek out a program that can help guide you through the process.

The National Committee for Quality Assurance (, the American College of Physicians (, the Commonwealth Fund (, the Patient-Centered Primary Care Collaborative (, the American Academy of Family Physicians (, and the Agency for Healthcare Research and Quality ( are just a few of the organizations that have guides, online tools, and resources to help walk practices along the path to PCMH certification.


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