Technology, care coordination, redefining staff roles keys to implementation success

From the earliest days of professional medicine, the idealized image of the doctor-patient relationship has been the wise physician reviewing information, diagnosing illness, and offering treatment and advice.

Giving patients the encouragement and information they need to manage their treatment, prevent illness, and meet other healthcare needs is better for patients-and for you. More recently, however, the idea of patients becoming care participants-rather than passive recipients-has taken hold, most prominently with the concept of the Patient-Centered Medical Home (PCMH). In PCMHs, physicians-usually those who specialize in primary care-partner with patients to see that care is coordinated rather than piecemeal, and give patients the information they need to tackle their health issues in a proactive, practical, and knowledgeable manner.

“The [PCMH] is the modernization of primary care medical practice away from brief, episodic visits to a continuous process of communication and care,” says Joseph E. Scherger, MD, MPC, a family physician in La Quinta, California, and a member of the Medical Economics editorial board.

Fred Ralston Jr., MD, an internist in Fayetteville, Tennessee, and a past president of the American College of Physicians (ACP), points out that becoming a PCMH allows a practice to move toward population management in a structured way, with lessons learned from others who have gone through the process.

“For patients, there is enhanced access and coordination of care with other health providers,” he says. “For primary care physicians [PCPs], there is the real potential to move toward a practice and payment model that works. The PCMH allows quality improvement to be a process that flows more smoothly than in the past.”

Here are six steps you can take to become a PCMH.

1. Invest in an EHR

Ralson’s eight-doctor practice, Fayetteville Medical Associates, adopted the PCMH model in 2010.

“BlueCross BlueShield of Tennessee was looking to expand a pilot program, which they now call an implementation program, to more practices,” he explains. “From their perspective, our use of an electronic health record [EHR] since 2004, and my understanding of the PCMH from ACP experiences, made our practice a good place for a medical home.”

For practices looking to become PCMHs, investing in an EHR is step 1.

“An EHR is not officially a medical home requirement,” says Jeffrey J. Cain, MD, a family physician in Denver, Colorado, and president of the American Academy of Family Physicians (AAFP), “but enhanced information technology is very useful in implementing patient-centered practices.”

Similarly, Scherger notes that no practice will continue for long in the evolving area of quality measurement and reporting without an EHR.

That’s because the PCMH is all about a care team “owning” the patient, which means coordinating care and tracking everything, says Rosemarie Nelson, a principal with the Medical Group Management Association Health Care Consulting Group, who helps physician practices convert from paper to digital records.

“A reliable electronic health record supports a preventive approach; without an EHR, physicians need to open and close charts over and over to try to identify which patients are due for screening diagnostic tests, immunizations, follow up services, and so forth,” she says.

Nelson also notes that the PCMH must track patient referrals to specialists and other clinicians for incoming results and mine data to identify which patients are due-or past due-for preventive as well as disease-specific care. “These are grounded on evidence-based medicine protocols and quality metric reporting-for example, how many patients have an HbA_1c below 9. Such processes are unwieldy in a paper-based charting practice,” she says.

Some EHR vendors offer assistance specifically for practices that wish to become PCMHs. For example, athenahealth in August 2011 began offering what it calls its Accelerator Program, designed for those seeking National Committee for Quality Assurance (NCQA) recognition. The company’s EHR helps practices tracking measures achieved and run reports against a patient panel, and the program further helps practices with document services such as those related to pre-validation for test and referral tracking. (See www.athenahealth.com/blog/2011/08/29/athn-ncqa-a-faster-path-to-pcmh/ for more information and check with your vendor to see what services it offers.)

2. Review operating principles

Peggy Reineking, director of recognition programs for the NCQA, recommends that a practice looking to become a PCMH transform its operations in accordance with the Patient Centered Primary Care Collaborative’s Joint Principles of the PCMH. The complete list of specifications, which can be accessed at www.pcpcc.net/joint-principles, includes the following:

• Each patient must have an ongoing relationship with a personal physician trained to provide continuous, comprehensive care.

• The physician is responsible for addressing all the patient’s healthcare needs, including acute care, chronic care, preventive services, referrals to other qualified medical professionals, and end-of-life care.

• Care should be coordinated across all features of the healthcare system (subspecialists, hospitals, home health agencies, nursing homes) as well as family and community-based services.

• Appropriate information technology, health information exchange, and community resources should be used to ensure that patients get care when and where they need it.

3. Select a care coordinator

A PCMH requires a patient care coordinator to oversee the process. Scherger, whose 14-physician practice, Eisenhower Primary Care 365, is a PCMH, recommends selecting someone who is both empathetic and computer savvy.

“This is population management,” he says. “A nurse who is sensitive to patients’ needs and some quality improvement background will probably be a good choice.”

In Ralston’s practice, Fayetteville Medical Associates, the care coordinator initially served as a liaison with other groups that were at various stages of the same process.

“Each practice cannot and should not attempt to reinvent the wheel, but learn from others and later teach the newcomers,” he says. “As the PCMH develops, more time is spent on care coordination and less on setting up the processes.”

Most specialty societies have online and other resources for members who want to transform their practices into PCMHs. The AAFP’s Web site, for example, features a PCMH checklist (www.aafp.org/online/etc/medialib/aafp_org/documents/membership/pcmh/checklist.Par.0001.File.tmp/PCMHCklist.pdf) that highlights PCMH-related quality care, health information technology, and practice organization. (See “Medical society resources for becoming a PCMH,” below, for additional links related to professional organizations. See www.MedicalEconomics.com/PCMHresources for additional information related to PCMHs.)

4. Consider seeking recognition

Although an official stamp of approval isn’t required for practices to brand themselves as PCMHs, formal recognition has many benefits.

“The majority of the NCQA-recognized PCMH practice sites receive financial rewards from their state Medicaid agencies or commercial insurance companies. These payer organizations believe strongly in the PCMH model, and they rely on recognition processes to ensure that practices are operating as such,” says the NCQA’s Reineking.

The NCQA is the most prominent organization in PCMH recognition, having recognized 3,302 sites and 16,191 clinicians by the end of 2011, according to its annual report from that year (an increase from 1,507 sites and 7,698 in clinicians just since the beginning of 2011).

In addition to the NCQA, organizations that provide PCMH recognition or accreditation include the Accreditation Association for Ambulatory Health Care, the Joint Commission, and the Utilization Review Accreditation Commission. (See “Recognition and certification bodies,” below, for links to these organizations.)

Recognition process vary depending on the agency. Practices seeking to become an NCQA-recognized PCMH, for example, must complete an electronic survey that focuses on how well the practice:

• enhances access and continuity,

• identifies and manages patient populations,

• plans and manages care,

• provides self-care support and community resources,

• tracks and coordinates care, and

• measures and improves performance.

Conrad Flick, MD, whose practice, Family Medical Associates of Raleigh in North Carolina, initially achieved NCQA recognition in 2009, says that the practice approached the PCMH concept as a means of staying ahead of the curve as the healthcare system evolves.

“We have always tried to take care of our patients in a way we would want our families and ourselves to be treated,” Flick says. Because the practice implemented an EHR system several years ago, the group members believed that they already were meeting key PCMH requirements and that official recognition could potentially lead to improved outcomes for patients and a more efficient practice.

No across-the-board figures exist on the percentage of primary care practices that have attained PCMH status, but a 2011 ACP membership survey indicated that nearly one-third of members reported their practice/medical group had received recognition/certification as a PCMH or was in the process of pursuing recognition/certification.

According to Michael S. Barr, MD, MBA, senior vice president of the ACP’s professionalism and quality division, 37% of physicians who report that their practice/medical group has received recognition/certification as a PCMH work in an integrated multispecialty system, 20% work primarily in a hospital, 15% work in an academic medical center, and 14% are private practitioners.

An AAFP Practice Profile survey of active members in that organization indicated that in 2010:

• 8% had practices that were recognized as PCMHs by NCQA,

• 3.6% were in practices recognized as PCMHs by a health plan,

• 2.6% had practices that were recognized as PCMHs by a state entity, and

• 2.7% were in practices recognized as PCMHs by “another entity.”

5. Clarify roles in the practice

Change can be frightening, Ralston acknowledges.

“In particular,” he adds “[PCPs] have seen many new ideas come and go over the years, and many of these ideas put tremendous strain on the practice with no discernible benefit. That being said, there is a moment of true relief when enough transition has occurred to indicate that adopting the PCMH model makes life easier rather than harder for physicians.

“I was relieved when I began to understand that the detail work of the PCMH was up to staffers. My role, which I enjoy, is more to agree to clinical standards and take care of patients. This is the true meaning of team-based care.”

6. Communicate with patients

AAFP President Cain encourages practices to communicate with patients when they begin PCMH-related transformation.

“Patient engagement is critical,” he says. “This engagement starts with including patients in the redesign plans. Patients can offer valuable insights to members of the care team as they seek to evaluate workflow and restructure the practice to improve the patient experience, quality, and efficiency.”

It is also important that practices keep patients “in the loop” by apprising them of PCMH-associated changes and the benefits of those changes. Ideally, Cain says, this information will spark conversations with individual patients about being active partners in managing their health.

Some practices inform patients about PCMH via brochures. Others send out e-mail or snail-mail letters, post PCMH-related information on the practice’s Web site or on a social media outlet, or impart the information via face-to-face conversations. The Phoenix, Arizona-based practice of family physician James J. Dearing, DO, developed a patient focus group to make sure that the evolving PCMH met patient needs.

“It also helped them understand the process problems. They were much more tolerant knowing we were striving for a better product,” he says.

Many patients who initially are wary are won over when they experience PCMH benefits first-hand. Dearing’s patients, for example, appreciate the extended hours that the practice now offers, and the fact that the practice identifies and reaches out to patients who have chronic diseases but who have not made appointments as necessary.

Flick and his colleagues display their PCMH recognition certificates in every exam room, which generates conversations between providers and patients. They also write about the PCMH in the practice’s newsletter and post announcements on the practice Web site.

“In addition, we talk about the PCMH as a reason why we do more prescriptions electronically, provide more educational material, and ask patients to follow up consistently, use our patient portal, and communicate with us as needed,” he says.

Flick continues: “Some patients don’t see the value of developing a personal relationship with a [PCP], or do not value ongoing care as a means of preventions and health maintenance. But if you take time to explain these approaches to patients, they respond positively.

“As we move forward with things like improved coordination and transition of care and as we identify patients who will require more or different services to stay healthy, I am certain our [PCMH] will elicit more positive feedback. For patients, there is really no downside.”

Ralston expresses similar sentiment. In his view, “many patients and doctors equate good primary care with a PCMH. It is a way to add that 10% or 15% of extra patient benefit to make a good practice a truly great one.”

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Our PCMH series

Be sure to watch for future articles in our series on Patient-Centered Medical Homes, which will inform you:

• financial benefits to becoming

• a medical home,

• how to define and measure success,

• how to incorporate continuous care into your practice and get paid for it,

• strategies for tracking referrals,

• using technology in medical homes,

• resources to help you succeed, and

• more.

Medical society resources for becoming a PCMH

Professional societies offer tips and insights into Patient-Centered Medical Homes from the perspective of the type of doctor they represent. Here are some of the primary care-related online resources available.

• American Academy of Family Physicians (AAFP)www.aafp.org/online/en/home/membership/initiatives/pcmh.html

• AAFP subsidiary TransforMED’s Medical Home Facilitation Program and other resourceswww.transformed.com/MedicalHomeFacilitation/index.cfm and www.transformed.com/resources/PCMH.cfm

• American College of Osteopathic Family Physicians www.acofp.org/Practice_Management/ACO/Medical_Home/

• American College of Physicianswww.acponline.org/running_practice/delivery_and_payment_models/pcmh/

• American Osteopathic Association www.osteopathic.org/osteopathic-health/about-your-health/Pages/patient-centered-medical-home.aspx

• Society of General Internal Medicine www.sgim.org/communities/clinical-practice/pcmh

Recognition and certification bodies

Organizations offering formal recognition, certification, or standards for Patient-Centered Medical Homes (PCMH) provide a wealth of information to those considering becoming a PCMH, those in the process of converting their practices, and those who already have changed their practices to PCMHs.

• Accreditation Association for Ambulatory Health Care www.aaahc.org/accreditation/primary-care-medical-home/

• Health Care Incentives Improvement Institute (through its Bridges to Excellence program) www.hci3.org/recognition_programs/bte_medical_home

• The Joint Commission www.jointcommission.org/accreditation/pchi.aspx

• National Committee for Quality Assurance www.ncqa.org/ppcpcmh

• URAC (formerly the Utilization Review Accreditation Commission) www.urac.org/pchch/