The Patient-Centered Medical Home Model

Jasmine D. Gonzalvo, PharmD, BCPS, BC-ADM, CDE, LDE

Clinical Associate Professor

College of Pharmacy, Purdue University

Clinical Pharmacy Specialist, Ambulatory Care

Eskenazi Health

OBJECTIVES

2

Define the patient‐centered medical home model (PCMH)

List essential components of a successful PCMH

Outline rationale for establishing a PCMH

Describe potential payment models for PCMHs

Provide details about the NCQA standards for PCMHs

OBJECTIVES

3

Patient Centered Medical Home: 

Defined

MEDICAL HOME BACKGROUND

4

1967

• American Academy of Pediatrics (AAP) introduced medical home concept

• Referred to a central location for archiving a child’s medical record

2001• Institute of Medicine Crossing the Quality Chasm report calls for redesign of healthcare in the United States

• PCMH model may address many concerns raised in this report

2002

• AAP expanded medical home concept  to include care characteristics such as: accessible, continuous, comprehensive, family‐centered, coordinated, compassionate, and culturally effective

2004 • American Academy of Family Physicians (AAFP) developed medical home model

2006 • AAFP launched the National Demonstration Project (NDP) on a national sample of practices designed to test PCMH models

2007 • ACP, AAFP, AAP, and AOA published Joint Principles of the PCMH

Institute of Medicine. Committee on Quality of Health Care in America. Cross the Quality Chasm: A new Health System for the 21st century. Washington, DC: National Academy Press; 2001.Ann Fam Med 2010;8(1):s80-s90.

U.S. MEDICAL HOME MODELS

5https://www.pcpcc.org/initiatives/national

MEDICAL HOME MODEL – DEFINED

6

• Core features• Widely accepted model for how primary care should be

organized and delivered throughout the health care system• Philosophy of health care delivery that encourages providers and

care teams to meet patients where they are• Place where patients are treated with respect, dignity, and

compassion, and enable strong and trusting relationships with providers and staff

• PCMH is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs

Model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated,

accessible, and focused on quality and safety

https://www.pcpcc.org/about/medical-home

MEDICAL HOME MODEL – DEFINED

7

• Core features• Provides enhanced primary care services of value to patients,

their families, and the care teams who work with them• Provides improved access to high-quality, patient-centered

primary care through trusted relationships with patients, families, and caregivers

• Incorporates team-based care with clinicians and staff working at the top of their skill set

• Provides cost-effective care coordination and population health management connecting patients to the “medical neighborhood” and to their community

An innovation in care delivery designed to advance and achieve the Triple Aim of improved patient experience, improved population health, and reduced cost of care

Nielsen, M., Buelt, L., Patel, K, & Nichols, L.(2016). The Patient‐Centered Medical Home's Impact on Cost and Quality, Review of Evidence, 2014‐2015. ‐See more at: https://www.pcpcc.org/resource/patient‐centered‐medical‐homes‐impact‐cost‐and‐quality‐2014‐2015#sthash.MNtkVtTI.dpuf

Joint Principles of PCMH

8

PCMH

Personal Physician

Physician‐directed Medical Practice

Whole Person 

Orientation

Care is coordinated 

and/or integrated

Quality and Safety

Enhanced Access

Payment

AAFP, AAP, ACP, AOA Joint Principles of PCMH

http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/why-pcmh/overview-of-pcmh/the-medical-home-neighborhood

Personal Physician

11

Essential Components

Personal Physician

12AAFP, AAP, ACP, AOA Joint Principles of PCMH

Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care

Physician Directed Medical Practice

13AAFP, AAP, ACP, AOA Joint Principles of PCMH

The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

Whole Person Orientation

14AAFP, AAP, ACP, AOA Joint Principles of PCMH

The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals

Includes care for all stages of life: acute care, chronic care, preventive services, and end of life care

Coordinated/Integrated Care

15AAFP, AAP, ACP, AOA Joint Principles of PCMH

Care is coordinated or integrated across all elements of the complex health care system and the patient’s community

Care facilitated by registries, information technology, and health information exchange to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner

Quality and Safety

16AAFP, AAP, ACP, AOA Joint Principles of PCMH

Practices advocate for their patients to support the attainment of optimal, patient‐centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family

Evidence‐based medicine and clinical decision‐support tools guide decision making

Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement

Patients actively participate in decision‐making and feedback is sought to ensure patients’ expectations are being met

Quality and Safety

17AAFP, AAP, ACP, AOA Joint Principles of PCMH

Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

Practices go through a voluntary recognition process by an appropriate non‐governmental entity to demonstrate that they have the capabilities to provide patient‐centered services consistent with the medical home model

Patients and families participate in quality improvement activities at the practice level

Enhanced Access

18AAFP, AAP, ACP, AOA Joint Principles of PCMH

Available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff

Payment

19AAFP, AAP, ACP, AOA Joint Principles of PCMH

Appropriately recognizes added value for patients who have a PCMH

Value of physician, staff work, and ancillary services that falls outside of face‐to‐face 

visit

Support adoption and use of health information 

technology and quality improvement

Support provision of enhanced communication 

access

Recognize the value of physician work associated with remote monitoring of clinical data use technology

Payments for care management services that fall outside of the face‐to‐face visit should not result in a 

reduction in the payments for face‐to‐face visits

Recognize case mix differences in the patient population being treated 

within the practice

Allow physicians to share in savings from reduced 

hospitalizations associated with physician‐guided care management in the office 

setting

Allow for additional payments for achieving measurable and 

continuous quality improvements

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Rationale

The patient‐centered medical home can help health centers meet their clients’ care needs in a more coordinated, effective way.

Medical Homes are more prepared to undertake quality improvement activities, which can improve health outcomes and 

lower costs.

Medical Homes can provide access to the nonmedical services that many low‐income people need, such as transportation, nutritious 

food, and supportive housing.

Access to behavioral health services and dental care improves with medical home implementation.

RATIONALE

http://www.commonwealthfund.org/publications/lists/community-health-centers-becoming-medical-homes-top-5

SUCCESSFUL MEDICAL HOME MODELS

22 Grumbach K, Grundy P. Outcomes of implementing patient centered medical home interventions: a review of the evidence from prospective evaluation studies in the United States.

Organization Raised quality ↓ Total Spending ↓ ED U liza on ↓ Inpa ent U liza on

Group Health Cooperative of Puget Sound

IntermountainHealthcare Medical Group

BlueCross BlueShield of South Carolina

BlueCross BlueShield of North Dakota

Metropolitan Health Networks of Florida

Community Care of North Carolina

Colorado Medicaid ans SCHIP

CONFLICTING EVIDENCE

23 http://www.commonwealthfund.org/publications/in-brief/2017/mar/patient-centered-medical-homes-systematic-differences

The National Demonstration Project (NDP) examined PCMH models over 2 years in a diverse sample of 36 family practices

11 PCMH initiatives did little to improve costs, utilization, or quality

Neither inpatient admissions nor ED visits declined for PCMH patients compared to study 

controls and most quality metrics were unchanged

PCMH vary significantly due to differences in their design and implementation

HOW TO BUILD A PCMH

24

The National Demonstration Project (NDP) examined PCMH models over 2 years in a diverse sample of 36 family practices

Start small and build• Initially make changes for a small group of patients and build from lessons learned

Use data to understand your patient population• Stratify patients by age, chronic condition, and risk levels to learn best practices for care management

Think long term; think partnership

Engage patients and families

FIRST YEAR COSTS

25

• Proposed first year costs for one physician practice utilizing existing staff can range from $10,500 to $52,100

• Proposed first year costs for a five physician practice with two health coaches can range from $126,000 to $346,500

• Costs take into consideration: RN health coaches Medical home administration time Training costs and associated lost revenue EMR implementation Disease registry NCQA certification Point of care lab testing supplies Patient education supplies Miscellaneous costs

26

Payment Models

Primary Care Payment Models

27

CMS Alliance to Modernize Healthcare

https://www.mitre.org/centers/cms-alliances-to-modernize-healthcare/who-we-are

Primary Care Payment Models (PCPMs)

28

Reduce administrative burden, encourage team-based approaches to primary care and care coordination, and

allow the flexibility needed to innovate value-based delivery approaches, particularly with respect to

establishing connections between primary care and behavioral health and community services.

Nielsen, M., Buelt, L., Patel, K, & Nichols, L.(2016). The Patient‐Centered Medical Home's Impact on Cost and Quality, Review of Evidence, 2014‐2015. ‐See more at: https://www.pcpcc.org/resource/patient‐centered‐medical‐homes‐impact‐cost‐and‐quality‐2014‐2015#sthash.MNtkVtTI.dpuf

Primary Care Payment Models

29Health Care Payment Learning & Action Network. Accelerating and Aligning Primary Care Payment Models White Paper. February 28, 2017.

Support high value primary care that fosters health for all patients, expands access to 

innovative methods of delivering  effective care, and minimizes disparities 

in care

Need to allow primary care practices to focus on work that promotes the 

health of patient populations and 

minimize work that does not contribute to high‐

quality care

Enhance collaboration with specialists, 

hospitals, and EDs, to deliver timely, 

appropriate, and efficient care

Promote excellent clinical and patient experience outcomes  that reflect 

patient goals and whole‐person care, to enable 

health care professionals to partner with patients and families to achieve 

the outcomes they desire

Encourage robust integration of primary care, behavioral health, and strong linkages with community resources to 

address social determinants of health

Promote multifaceted efforts to make 

caregivers and patients partners in the delivery 

of their care

Need to collaborate in partnerships to ensure the success of PCPMs

Primary Care Payment Models

30Health Care Payment Learning & Action Network. Accelerating and Aligning Primary Care Payment Models White Paper. February 28, 2017.

31

NCQA Standards

http://store.ncqa.org/index.php/recognition/patient-centered-medical-home-pcmh.html?___SID=U

LESSONS

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• Establishing a PCMH is a significant undertaking

• Long‐term success of any PCMH implementation depends on practices’ ability to manage a successful, efficient practice in an environment of constant change

• It is easy to lose sight of the patient in developing a PCMH

• Specific components of the PCMH that contribute to successful outcomes should be identified

• NCQA recognition may be helpful in the development of a PCMH

RESOURCES

34

• National Committee for Quality Assurancehttp://www.ncqa.org/tabid/631/default.aspx

• National Center for Medical Home Implementation  (American Academy of Pediatrics)http://www.medicalhomeinfo.org/national/projects_and_initiatives.aspx

• Patient‐Centered Primary Care Collaborative https://www.pcpcc.org/

The Patient-Centered Medical Home Model

Jasmine D. Gonzalvo, PharmD, BCPS, BC-ADM, CDE, LDE

Clinical Associate Professor

College of Pharmacy, Purdue University

Clinical Pharmacy Specialist, Ambulatory Care

Eskenazi Health