Author Name Jennifer Bresnick | Date July 28, 2014
The patient-centered medical home (PCMH) is becoming one of the most coveted recognitions for healthcare providers in urgent need of better ways to manage population health, close care gaps, and reduce wasteful spending. As evidence of the model’s effectiveness mounts in conjunction with the shift towards accountable care reimbursement models, what are some of the most critical building blocks for the medical home, and how can providers begin their journey towards developing a system of data-driven, patient-centered care?
The patient-centered medical home (PCMH) is becoming one of the most coveted recognitions for healthcare providers in urgent need of better ways to manage population health, close care gaps, and reduce wasteful spending. As evidence of the model’s effectiveness mounts in conjunction with the shift towards accountable care reimbursement models, what are some of the most critical building blocks for the medical home, and how can providers begin their journey towards developing a system of data-driven, patient-centered care?
Roadmap to success
Providers can operate under the PCMH model without being officially recognized as such, but organizations such as NCQA and the American Academy of Family Physicians (AAFP) offer roadmaps and planning tools to guide providers towards the principles of PCMH operations. Providers may also wish to bring in consultants that will examine their operations, workflows, and clinical health IT infrastructure maturity while making suggestions about the next steps towards developing strong relationships with patients and partner organizations.
Providers should be aware, however, that moving to the PCMH model does require significant investment in both time and resources, warns Michael Meucci, Director of Transformation and Improvement at Arcadia Healthcare Solutions. “The medical home is a really resource-intensive model,” he says. “You go from having a physician who has a one-on-one relationship to a patient to a team-based model where a team has a relationship with the patient.”
Strong leadership and staff commitment
The most important key for success is a strong commitment to that overall transformation, a clear leadership structure that engages all levels of staff, and effective communication within the organization as changes are being made. “When we look at some of our most successful transformations, we see strong leadership buy-in,” Meucci says. “[One client] built a steering committee that was made up of representation from the executive leadership team, practice leadership, medical leadership, and technology leadership. It was really every functional area of that organization that was represented on this team.”
“One of the comments that we heard from [our client organization’s staff] was that they were excited to be asked questions about their patients and their care, because historically they had just been given edicts in terms of what they needed to do, and then they were expected to go do it without question,” adds LuAnn Kimker, RN MSN, CPHIMS, PCMH CCE, Director of Clinical Quality Improvement at Arcadia Healthcare Solutions.
In health systems with multiple locations, the PCMH model can help to standardize workflow and clinical tasks throughout the organization, leading to a reduction in potentially harmful variations and an increase in overall quality, communication, and adherence to the organization’s goals.
“The PCMH model really standardizes things across health centers,” said Carol Mensch, MSN RN-BC, Performance Improvement Coordinator at ChesPenn Health Services. “As a community health center, it really changes things to emphasize the patient-centered aspect of care. If we hadn’t gone the PCMH direction, the Healthy People goals we follow might have pushed us towards those population health features, as well. But having [the PCMH structure] helps us focus and channel some of our areas of need.”
An underlying technical infrastructure
While EHR adopters can succeed with many of the PCMH principles without an additional outlay in technological infrastructure, clinical analytics and population health management tools can expand a provider’s capabilities to conduct risk assessments, stratify patients, preempt non-adherence, and prevent 30-day readmissions that often come with a hefty financial penalty. Many of the most technologically savvy organizations in the nation have invested heavily in predictive analytics and data warehousing.
“We are using real-time algorithms within and outside of the EHR to look at risk, and predict and inform clinical and operational pathways,” says Steve Hess, CIO, University of Colorado Health, one of this year’s “Most Wired” hospitals. “While still early, we are starting to see patterns related to how our patients are interacting with our system and the reimbursement impact of those changes. It is important that our systems are set up to provide the complete patient picture and to ensure that the patient is getting the appropriate care in the appropriate setting at the right time.”
Effective patient engagement tools
In addition to in-house analytics, providers must invest in patient engagement if the PCMH is to be successful. Helping patients manage their chronic diseases, show up for screenings and other primary care services, and access their health information to improve literacy and encourage healthy choices are key features of the PCMH, and health IT tools are available to help. The patient portal is a pillar of Stage 2 meaningful use, and is a wildly popular feature with patients.
“We recently started a system-wide patient engagement education that includes media, TV, and print, encouraging patients to talk to their providers about using our portal,” explains Catholic Health Partners CMIO Stephen Beck, MD, FACP, FHIMSS. “The intent is to educate patients and continue to educate our providers as we realize there is some economy in the use of our patient portal.”
“Collaboration across the community is going to be a very positive outcome from this work,” he added. “Some communities are well connected right now with HIEs and other interaction at the community level, but most are still very competitive. By nature of making it easier to share information about patient care and improving continuity, I hope the patient will be the winner relative to meaningful use and HIE integration.”
Community stakeholder buy-in
Those community connections provide the foundation for a truly effective PCMH. Primary care providers can no longer work in isolation, sending patients out to specialists but rarely receiving feedback on the results. By working together as a “medical neighborhood” instead of individual organizations spending money and man-hours faxing documents back and forth, both providers and patients can reap significant benefits. Patients may not always understand their responsibilities when it comes to coordinating their care, and hospitals waste millions every year on inefficient communications, lengthy transitions, and waiting for information from colleagues.
“It is important for all health care professionals involved in patient care to have a solid understanding of the role of the patient and family in articulating needs and developing a care plan,” says AAFP. “PCMH integration enables warm handoffs at the moment the patient or family is ready and, thus reduces stigma, improves adherence and augments access to support groups, parenting programs and other medical neighborhood services.”
