The Future of the Patient Centered Medical Home: A Sneak Preview We are recruiting! CAFP plan is to work with family medicine sites to participate in our PCMH collaborator and achieve NCQA medical home recognition and transform their practices. We are participating with our partners at the California Primary Care Association and Arcadia Solutions. The activities will be sponsored for CME, IPIP, and Part IV Maintenance of Certification credit and a 50 percent discount on Arcadia’s PCMH Accelerator Portal. For more information, please contact Jane Cho at [email protected]. The movement to transform primary care, focused on advanced teamwork and population management, is hitting its stride. There are over 7000 medical home practices now recognized by the National Center for Quality Assurance (NCQA). The latest annual report by the Patient Centered Primary Care Collaborative on the impact of the Patient Centered Medical Home (PCMH)1 demonstrates its consistent and broad impact on cost and quality. Improvements are seen in population health measures (up 29 to 30 percent), patient satisfaction (up 14 to 23 percent) and access (up 14 to 31 percent). Reductions are seen in total cost of care (57 to 61 percent), hospitalizations (31 to 57 percent) and emergency department use (57 to 61 percent). Good but Not Good Enough: The current build of the medical home is not without its shortcomings. In a newly-­‐released white paper2 on the future of the PCMH, NCQA summarized the advanced model’s powerful impact but also reviewed its current weaknesses: • The focus on structure of advanced primary care practices with limited attention to outcomes; • The cost of the recognition process, implementation and maintenance of PCMH systems and infrastructure including electronic health records; • A payment structure that remains firmly rooted in fee-­‐for-­‐service models, providing poor, if any, financial support to offset the added costs of PCMH; • The lack of support in system redesign to promote effective behavioral health integration; • The focus of practice transformation is limited to primary care and a roadmap for specialty care practices and the growth of the medical neighborhood is absent; and • The unique challenges to small practices and difficulty providing them with the resources and leadership necessary for transformation. Evolution in Action: True to its commitment as a learning organization, NCQA began to extend the medical neighborhood last year with the release of the Patient Centered Specialty Practice Standards. Later this month, NCQA is releasing its 2014 PCMH Standards, which begin to answer the above concerns and build upon the successes of the previous three versions. Here is a preview of the new standards: 1. Additional emphasis on team-­‐based care. Empowering providers and support staff with huddles, standing orders, and outreach tools (e.g., registries and tracking systems) was 2.
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the first step towards patient centered teamwork. Now the role of the patient as a key teammate is further stressed through their participation in improvement activities. Higher bar for quality improvement (QI) activities. Practices must focus their improvement work in all three domains of the Triple Aim (i.e., patient experience, cost and clinical quality) and be able to demonstrate existing QI capabilities and outcome improvement efforts annually (subject to NCQA audit). Further integration of behavioral health into primary care practice. The updated criteria expand on the practice’s capabilities to treat unhealthy behaviors and conditions related to mental health or substance abuse. Tighter and effective collaboration with behavioral health providers is emphasized through new referral requirements. Care management is focused on high-­‐need populations. Practices are expected to systematically identify their high-­‐risk patients to better focus their care management, outreach and self-­‐management support activities. Criteria for defining these populations should consider social determinants of health, behavioral health, high cost/utilization, poorly controlled or complex conditions and patients referred for care. Alignment with Meaningful Use Stage 2 (MU2). Although MU2 is not a requirement for recognition, clinicians in practices that meet the 2014 Standards will be well positioned to qualify for MU2 payments. Well-­‐Being and Survival of the Fittest: Some of these changes mean a bit more work for practices compared to the 2011 Standards. But this direction is particularly powerful for our communities, our patients and the vitality of primary care. Notice the deliberate incorporation of the patient voice in the leadership of change and putting continuous back into continuous quality improvement -­‐-­‐ it is an accountability journey after all. More importantly, the 2014 Standards are driving closer to the heart of patient centering towards patient wellness. After all, what is health unless it blends an evidence-­‐based medical model with the patient’s perspective on their physical, mental and social health – their wellbeing? The truth about our health care model is that it is vitally important but only 20 percent of an individual’s health status is attributable to the health care services he or she receives. The rest is driven by socioeconomic, environmental and behavioral determinants. To help us move closer to understanding the health of our patients from their perspective and sense of wellness, we need a model of advanced medical homes with new tools. The 2014 Standards provides such a toolkit, one that begins to leverage these social determinants to develop more effective partnerships with essential community resources (e.g., behavioral health, social workers and educational resources). In this way, we will begin to maximize the impact of our health care model by being centered on what matters most to our patients: how they feel and their sense of wellness. • Wait for it! There will be a new name for the 2014 Standards released this month and it is top secret! • PCMH Purchase and Submission Dates: o PCMH 2011 -­‐ June 30, 2014 is the last date to purchase PMCH 2011 survey tools. December 31, 2014 is the suggested last date to submit PCMH 2011 corporate survey tools for multi-­‐site submission. March 31, 2015 is the last date to submit PCMH 2011 survey tools. o
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PCMH 2014 -­‐ March 24, 2014 is the first day to purchase survey tools. Submit either version between March 24, 2014 and March 31, 2015. References: 1. “The Medical Home’s Impact on Quality and Cost: an Annual Update on the Evidence, 2012-­‐2013. January 2014. Marci Nielsen, PhD, MPH
J. Nwando Olayiwola, MD, MPH Paul Grundy, MD, MPH
Kevin Grumbach, MD. PCPCC 2. The Future of the Patient-­‐Centered Medical Homes: Foundation for a Better Healthcare System. February 2014. NCQA. Dr. David Ehrenberger is Chief Medical Officer of Avista Adventist Hospital and Integrated Physician Network, an Accountable Care Organization north of Denver. He practices medicine part-­‐time in a Level III NCQA recognized medical home. He may be reached [email protected]