1. A Step by Step Approach to Building a Patient-Centered Medical Home

2. What Does That Mean for One Patient?
Ms. Jones, a 55 year old diabetic, is a patient of Dr. Smith’s practice
In 2010, Ms. Jones:
Showed poor understanding of her diabetes and link between diet and blood sugar readings
Rarely checked her blood sugar at home
Did not consistently take her medications for diabetes or high blood pressure
Hgb A1-C  >10;  BP 170/110; Wt. 165
Went to ER 5 times with complaints of headache and blurred vision; an infected foot ulcer; pain and tingling in her feet   
In 2011, Ms. Jones:
Met 1:1 with the Diabetes Educator and attended group diabetes classes with her husband
Learned how to check and record her blood sugar results daily
The Care Manager helped her obtain low cost medications from a pharmaceutical company
Hgb A1-C down to 8.3; BP 140/80; Wt. 143
Went to ER once for chest pain and shortness of breath  
Case Manager coordinated her referral to cardiologist
Dr. Smith’s practice in 2010
Dr. Smith’s practice in 2011 as a PCMH

3. Key Points from the Patient - Centered Primary Care Collaborative February 2016 Annual Update Report
PCMH studies continue to demonstrate impressive improvements across a broad range of categories including: cost of medical care, utilization of services, population health, prevention, access to care, and patient satisfaction.
Advanced primary care is foundational to delivery system transformation. The PCMH model continues to play an important role in strengthening the larger health care system, particularly Accountable Care Organizations and other integrated healthcare delivery systems.
Payment reform is necessary to sustain delivery system changes. Multiple payment innovation models are currently being tested, such as pay-for-performance; per member per month (PMPM) payments, often adjusted for PCMH Recognition level, in addition to FFS billing; and/or shared savings arrangements.

4. PCMH Success: Examples of PCMH results
Initiative
Health Cost & Utilization Outcomes
Health Outcomes
Years of Data Review
Patient Satisfaction
PA Chronic Care Initiative
All- cause hospitalization reduced 1.7%
All - cause ED visits reduced 4.7%
Specialty visits reduced 17.3%
Higher performance 4 Diabetes measures including HbA1c testing and eye exams; and breast cancer screening
10/2007-9/2012
North Carolina: Community Care of North Carolina (Medicaid)
Decreased spending almost all categories
Reductions in readmissions, inpatient admissions for diabetes, ED visits for asthma
Approx. 10.7% decline in prescription drug use
Colorado Multi-Payer PCMH Pilot
9.3 % fewer ED visits
Reduction in ED costs of $3.50 PMPM
10.3% reduction in ACSC inpatient admissions
Increased cervical cancer screening rates
Source: The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence ; February 2016

5. What Is a Patient-Centered Medical Home?
Defined as “a team-based model of care led by a personal physician who provides continuous, coordinated care throughout a patient’s lifetime, to maximize health outcomes.” (American College of Physicians)
The PCMH provides or arranges for all of the patient’s healthcare needs, including:
Preventive care
Treatment of acute and chronic illnesses
Assistance with end-of-life/palliative care
Key building blocks: teamwork, leadership, communication, willingness to change

6. Core Components of a Patient - Centered Medical Home
Transformation of care delivery to become a model of primary care, delivering care that is:
These core components track closely with NCQA’s PCMH Recognition Standards.
Patient centered
Comprehensive
Coordinated
Accessible
Continuously focused on improvement through systems-based approach to quality and safety
Source: Agency for Healthcare Research and Quality- An agency within the Department of Health & Human Services committed to improving care safety and quality

7. Key Attributes of a PCMH
Physician Leadership/
Engagement
Team-based approach to care delivery
Use of Evidence-based Medicine and Clinical Decision Support Tools
Identify and Measure key Quality Indicators
Use of Health Information Technology

8. Characteristics of a PCMH
Ensure continuity of care
Identify and manage high risk patients
Develop and document patient self-management care plans
Involve patients and caregivers in shared decision making

9. Implementing a PCMH Model of Care: Factors to Consider
Ensure that you will get a return on your investment
Assess the state of your system, when applicable
Assess the state of your practices
Determine any gaps in care & service delivery in relation to the PCMH Standards
Calculate the cost of PCMH implementation
Calculate the potential benefits, including opportunity for higher reimbursement based on PCMH Recognition

10. Creating a Profile of Your Patients
Focus
Priorities
Estimated percentage of Patient Panel
Complex care patients
Intensive, multi-disciplinary care coordination in a community-based model 5%
High risk chronic care
Need for aggressive, ongoing monitoring of symptoms, focus on compliance
15%
Lower risk chronic care patients
Longitudinal monitoring of symptoms with focus on managing risk factors
25%
Healthy / chronic disease risk
Longitudinal monitoring and management of risk factors
20%
Healthy / primary prevention
Focus on prevention
0-5 children / compromised or at risk
Aggressive, early, multi-disciplinary intervention emphasizing parent engagement
0-5 healthy children / primary prevention
Protocol driven primary prevention
10%

11. Building an Interconnected, Patient-Centric Care System
The resulting COHC project design began with 1) development of an individualized plan of care 2) activation of the Health Engagement Team, 3) a patient advocate provided as needed (Community Health Worker), and 4) behavioral health care staff embedded in the primary medical homes. This multi-disciplinary team approach grounded in the individualized care plan has emphasized and supported primary medical homes and provider engagement at every step along the way, increasing collaboration in the care of each patient.

12. Becoming a PCMH Evaluate current work processes GAP ANALYSIS
Improvement plan & implementation
NCQA Accreditation
Getting paid for value

13. Process for NCQA Recognition
Purchase survey tools
Submit application
Obtain approval to apply for multi-site PCMH
Internal review
Documentation for Standards & Elements
Complete online tool
Upload appropriate documentation
Participate in NCQA PCMH Learning Initiatives
Follow required NCQA registration
Self-assessment
Recognition decision within 60 days of site Survey Tool submission.

14. NCQA Recognition Program
The National Committee for Quality Assurance (NCQA)’s Patient-Centered Medical Home Recognition Program provides a roadmap to physician practices working to improve care delivery and the experience of care for both patients and clinicians.
The six Standards align with the core components of primary care
Three possible Recognition Levels: Level I-III
Based on total points scored on the Recognition application
Six PCMH Recognition Standards
Patient -Centered Access
Team-Based Care
Population Health Management
Care Management & Support
Care Coordination & Care Transitions
Performance Measurement & Quality Improvement

15. NCQA Must-Pass Elements
Six Must - Pass Elements considered essential to a successful PCMH and required to achieve recognition at any level:
1A: Patient-Centered Appointment Access
2D: The Practice Team
3D: Use Data for Population Management
4B: Care Planning & Self-Care Support
5B: Referral Tracking and Follow-up
6D: Implement Continuous Quality Improvement

16. Enhance Access and Continuity
*Must earn a score of 50% or higher to pass this element

17. Provide Team-Based Care Continuity

18. The Practice Team
*Must earn a score of 50% or higher to pass this element

19. Plan and Manage Care

20. Use Data for Population Management
*Must earn a score of 50% or higher to pass this element

21. Provide Self-Care Support and Community Resources

22. Provide Self-Care Support and Community Resources
*Must earn a score of 50% or higher to pass this element

23. Track and Coordinate Care

24. Track and Coordinate Care
*Must earn a score of 50% or higher to pass this element

25. Measure and Improve Performance

26. Measure and Improve Performance
*Must earn a score of 50% or higher to pass this element

27. Appendix 1 – Scoring Sheet

28. Fundamentals Getting Started: Evaluate Current Work Processes
Revenue Cycle
Ability to manage documentation, billing, and collections
Efficient patient flow
Is it patient -centric?
Information Technology
Do you have a robust platform that all staff members can use effectively?
Data Reporting
Are you sending information to your providers on a regular basis?

29. Next level of requirements
Evaluate Current Work Processes
Next level of requirements
Governance
- Do you engage your physicians in decision-making?
Provider compensation
- Can your compensation structure accommodate quality metrics?
Human Resources
- Do you have the right mix of staff members and are they in the right positions?
Cost of Service
- How much does it cost the practice to offer a given service?

30. Gap analysis Evaluate Current Work Processes Revenue cycle
Efficient patient flow
IT platform
Data reporting
Governance
Provider compensation
Human Resources
Cost of Service
Evaluate current care and service delivery
Pay particular attention to the NCQA Must - Pass Elements
Determine priorities and identify “low-hanging fruit” to begin transforming care delivery
Key questions to consider:
Is the Practice organized to be “patient-centered” or “physician/provider-centered”? Example-
Appointment accessibility:
Is time reserved for same-day appointments?
Are extended office hours offered, to include evening/weekend appointments?
Are patient calls and electronic messages consistently returned in timely manner?
Do providers practice independently in “silos” or are there strong, integrated care teams in place?
Is patient care generally episodic in nature and focused on acute care or longitudinal and focused on the whole person, including chronic disease management?
Is HIT available and consistently utilized to support care delivery?
Does the Practice utilize standardized processes, order sets, and evidence- based clinical guidelines to drive quality and consistency?
Does the Practice coordinate and track all diagnostic services and referrals?
Are processes in place to systematically collect data and review/evaluate outcomes of care and services?

31. Implementation Plan Implementing the PCMH Model of Care
Develop & implement standardized treatment orders/evidenced-based clinical guidelines
Utilize Disease Registries for population health management
Track and coordinate care across healthcare continuum
Exchange clinical information electronically with referral providers-build a strong “Medical Neighborhood”
Integrate comprehensive medication management program
Implementation Plan
Identifying the Gaps:
Evaluate current care and service delivery
Pay particular attention to the NCQA Must - Pass Elements
Determine priorities and identify “low-hanging fruit” to begin transforming care delivery
Key questions to consider:
Is the Practice organized to be “patient-centered” or “physician/provider-centered”? Example-
Appointment accessibility:
Is time reserved for same-day appointments?
Are extended office hours offered, to include evening/weekend appointments?
Are patient calls and electronic messages consistently returned in timely manner?
Do providers practice independently in “silos” or are there strong, integrated care teams in place?

32. NCQA Patient-Centered Medical Home (PCMH 2014) Recognition Program - Standard Survey Pricing
Number of Clinicians in the Practice
Initial Fee for Practice to Obtain a Survey Tool License
Application Fees for NCQA Review and Recognition
Total License and Application Fees 1
$80
$550
$630 2
$1100
$1180 3
$1650
$1730 4
$2200
$2280 5
$2750
$2830 6
$3300
$3380 7
$3850
$3930 8
$4400
$4480 9
$4950
$5030 10
$5500
$5580 11
$6050
$6130 12
$6600
$6680 13
$ $55 for each clinician
$ $55 for each clinician

33. PCMH Implementation: Potential Challenges & Obstacles
Potential increased physician practice costs upfront: additional staff, expanded office hours, acquisition/implementation of Health Information Technology
Limited or no reimbursement by payors for PCMH infrastructure and care management/care coordination functions
Inconsistent availability/use of Health Information Technology
Must have functional EHR to achieve NCQA Level 3 Recognition
Lack of Electronic Health Record system interoperability between hospitals and physician practices
Physician collaboration and communication
Patient buy-in and participation in self-care management
Engagement and collaboration with community-based organizations

34. Questions 34

35. Resources
Patient Centered Primary Care Collaborative: 
National Committee for Quality Assurance :
American Academy of Family Physicians:

36. Thank You Contact for more information: Louise Bryde
Principal, Stroudwater Associates
mobile
Mike Fleischman