The Patient-Centered Medical Home (PCMH) is a primary care model that provides coordinated and comprehensive care to patients to improve health outcomes. This paper addresses practical issues that arise when transitioning a traditional primary care practice into a PCMH recognized by the National Committee for Quality Assurance (NCQA). Individual organizations' experiences with this transition were gathered at a PCMH workshop in Alexandria, Virginia in June 2010. An analysis of their experiences has been used along with a literature review to reveal common challenges that must be addressed in ways that are responsive to the practice and patients’ needs. These are: NCQA guidance, promoting provider buy-in, leveraging electronic medical records, changing office culture, and realigning workspace in the practice to accommodate services needed to carry out the intent of PCMH. The NCQA provides a set of standards for implementing the PCMH model, but these standards lack many specifics that will be relied on in location situations. While many researchers and providers have made critiques, we see this vagueness as allowing for greater flexibility in how a practice implements PCMH.
In response to the increasing demand for an improved healthcare system in the United States, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association developed the Joint Principles of the Patient-Centered Medical Home (Table
Joint Principles of Medical Home*.
Personal physician | (i) Patients have an ongoing relationship with a personal physician |
Physician directed medical practice | (i) Personal physician leads a team of individuals at the practice level |
Whole-person orientation | (i) Medical home provides for all the patient’s healthcare needs or appropriately arranges care with other qualified professionals |
Care is coordinated and/or integrated | (i) Coordination of care across the healthcare system and patient’s community |
Quality and safety | (i) Quality and safety improvement are hallmarks of the medical home |
Enhanced access | (i) Patients can easily access healthcare via their medical home |
Payment | (i) Increased payments support the added level of service and value provided to patients who receive care from a medical home |
*
Stenger et al. [
In spite of difficulty with the transition process, over 1,500 sites and 7,700 clinicians across the United States have successfully completed the National Committee for Quality Assurance (NCQA) recognition process and are functioning as Patient-Centered Medical Homes [
Carillion Clinic is a large healthcare organization located in Southwest Virginia, providing healthcare to individuals in both urban and rural settings. Their organization comprises over 600 physicians in multicare-specialty group practices and eight not-for-profit hospitals [
The Air Force has employed their version of the PCMH, termed the Air Force Patient-Centered Medical Home (previously the Family Health Initiative), at several of their bases within the United States. The Air Force PCMH was modeled after the qualities and goals of a PCMH. These Air Force PCMH practices are within the Air Force Bases themselves, and each of them has a patient panel of military beneficiaries (active duty members, retirees, and families) creating a unique healthcare environment because the Air Force operates under a complex healthcare and insurance system with both military care and purchased care (Our focus in this paper is on the onbase care provided by the Air Force and does not pertain to care purchased offbase through the Air Force’s TRICARE program).
From these healthcare organizations’ experiences, combined with a literature review of empirical work, this paper addresses the challenges and successes encountered in the transition to PCMH. The purpose of this paper is to realize the difficulties that arise in the transition into a PCMH across various settings and to provide solutions for practices to follow in their transition given their particular needs. This way these practices can provide better quality of care to patients, decrease patient’s health care costs, and improve the system as a whole. The paper is as follows, after a discussion of NCQA recognition, “Lessons Learned” discusses the most common concerns among primary care practices who have initiated the transition to a PCMH, which are promoting physician buy-in, changing office culture, care coordination, staffing and space allocations, and leveraging electronic medical records (EMRs). Under each of these topics, difficulties and successes are examined using specific examples provided by the PCMH workshop and previous studies.
The first step in the transition process is to understand what procedures and standards a primary care practice must follow in order to obtain recognition. Recognition as a PCMH increases the likelihood of reimbursement for the pioneering PCMH procedures that are currently undercompensated. As more studies discuss the positive results of PCMH, new reimbursement methods become more of an obtainable goal. For a practice to become recognized as a PCMH by the NCQA, the practice must provide documentation of the practice’s guidelines for implementation (Table
2011 Revised NCQA Standards for medical home recognition*.
Enhance access and continuity | Identify and manage patient populations |
Plan and manage care | Provide self-care support and community Resources |
Track and coordinate care | Measure and improve performance |
*NCQA [
Primary care physicians typically leave the workforce earlier in their careers than specialists with complaints of being overworked and poorly compensated [
The PCMH model recommends that practice staff and providers (nurses and physicians) take time to analyze patients’ needs as a whole. The model encourages practice leaders to empower ancillary staff to enlist protocols when meeting chronic, acute, and health maintenance needs. This team-based care is delivered prior to or after the provider encounter during a visit. The Air Force gave the following example of team-based collaboration when addressing a patient with a sprained ankle. First, the technician evaluates the patient and then performs the Ottawa ankle rules, which clearly delineate whether the patient requires an X-ray. Next, nurses will order X-rays based upon the results of the Ottawa ankle rules the technician provides. Subsequently, the skilled nurses return to educate the patient on ankle exercises and necessary bracing. Training a nurse to do this initial triage and intervention enables the provider to meet with the patient after X-rays are complete, which allows for a more efficient appointment. The team-based care creates a routine in which it is no longer necessary for a provider to address the patient each time they come to the practice. Many physicians are reluctant to release these face-to-face encounters with patients to their staff. This can be explained by the lack of training specific to PCMH practices, as well as the current reimbursement schedule, which encourage physicians to treat patients based on volume of care, rather than quality [
Second, the current form of financial reimbursement creates misaligned incentives for the physicians with their new responsibilities. For instance, according to the Medicare Resource-Based Relative Value Scale (RBRVS), physicians are only reimbursed for a patient visit if they can report a 15-minute office evaluation, discouraging the physicians from relinquishing any of their patients’ visits to their nurses [
In addition to the above-mentioned responsibilities of the physicians and their staff, the PCMH model introduces team-based care to primary care practices [
In spite of the current difficulty with physician buy-in to PCMH, we found that many physicians are inspired by their ability to provide patients with the quality care they deserve through PCMH. A lead primary care physician from a Carillion Clinic has seen an improvement in the health of patients due to the coordination and team-based care PCMH offers
The transformation of a primary care practice into a PCMH requires significant changes in office culture. In this section, we will discuss several areas that need to be addressed by the primary care practice, including nurse and patient experience.
Implementing the PCMH model is not as simple as assigning new staff roles and restructuring old staff with new titles. The healthcare organization must understand how changing positions within the practice brings new experiences to all of their current members and how these experiences can potentially affect their capability of delivering care [
In addition to providing new training for nurses, it is important also to train front office staff in their new roles as they play a part in carrying out several PCMH principles, such as ensuring greater access and increased communication. Both clerical and clinical staff members are encouraged to develop a more sophisticated level of decision-making skills, which may require additional training on the PCMH principles, new workflow processes in the office, and increasingly integrated responsibilities to patients and each other.
Every healthcare model must take into account patients’ response to the new healthcare structure. Patients value the respect, quality, and concern of their healthcare provider in addition to accessibility; their reaction to the change in structure significantly affects the ability of a team to provide care [
In PCMH, practices are tasked with improving care coordination and documenting patient engagement in self-management. This requirement has prompted many PCMHs to create a care manager or care coordinator position. This staff member (e.g., a nurse or nonclinical staff member) performs tasks that were previously delivered inconsistently or not at all, or that were formerly the responsibility of the physician, such as patient followups and patient education (When introducing the care coordinator to the patients, we encourage caution to avoid dramatization of past inadequacies in care delivery during patient and physician interactions, which could undermine their relationship with the physician [
Throughout the PCMH conference, discussants emphasized their success with care coordinators in their practices, many of whom have received positive feedback from their patients. For instance, a diabetic patient from one of Carilion Clinic’s Roanoke, Virginia practices reported
In addition to self-management coaching of those patients with chronic conditions, the care coordinators at Carilion Clinic have been assigned the task of population management. The care coordinators use registries (registries are a list of patients with a chronic disease displayed with many clinical features to stratify level of disease control), to focus on specific chronic diseases, such as high blood pressure and diabetes. Care coordinators use predetermined protocols to contact those patients in poor disease control or those who are due for a follow-up visit. Once these patients come back into the office, a number of things happen as they reengage with their care team. The nurse updates the health maintenance care in the chart, the provider focuses on the acute or chronic disease issues, and the care coordinator offers to meet with the patient, further identifying barriers they face that may interfere with disease self-management. A sophisticated EMR or free-standing disease registry facilitates this task. These technologies are used to organize and target the entire patient panel to track health indicators and in turn, isolate the patients of interest. This disciplined approach to population management is not typical in most primary care offices; therefore, this activity tends not to be included in the budget, and time is not allocated for it. If the transitioning PCMH practice is committed to carrying out population management work, there needs to be added space for this individual to work along with a private consultation area to perform the self-management coaching.
Along with refocusing the office culture to adhere to the new comprehensive level of care, PCMH connects patients with resources in the healthcare system and the community. Primary care practices need to take time to build collaborative relationships with other professionals, such as social workers, nutritionists, and health educators, to provide needed services. It is not feasible for most PCMH practice sites to have space on hand for these professionals to work side by side at all times.
The PCMH model does not require that a specific staff member document the services offered, ordered, or rendered, and neither does NCQA. Rather, what is important is that there is a workflow process in place for such documentation in patients’ medical records. For instance, at Carilion, ambulatory nurses have taken on roles in both chronic disease management and health maintenance. In some practices, nurses have taken on the documentation of all health maintenance needs of patients, while in others, this responsibility is shared among team members. No matter who plays what role, they need to be clearly within individual practice workflows and protocols.
There may be a period when nurses will need to familiarize themselves with the new structure. During this time, temporary staffing can be useful to reduce backlogged work. For example, the Air Force experienced a backlog problem with the transition of nurses from floor nurses to disease managers. The disease manager started as one of the nurses in the clinic but was taken out of patient treatment and put into this new position. The number of nurses available to care teams was then cut in third. The problem is that this created backfill, so the disease management nurses were not able to concentrate on the task at hand but instead needed to address the problems that arose in the practice during their training. Once the Air Force’s disease management nurses were able to focus on disease management, there was significant improvement in the quality of care for patients. It was also found in an outside study that patients who participated in chronic disease management had less frequent hospitalizations and on average spent 0.8 fewer nights in the hospital once admitted [
Carilion Clinic has also implemented disease management and has found that scanning the patient registry on a regular basis uncovers patients who would benefit from intensive disease management. In particular, one patient under Carilion’s care, a 70-year-old woman with diabetes, coronary artery d status after coronary artery bypass grafting, and congestive heart failure, was oxygen dependent and wheelchair bound. She was contacted after the care coordinator saw in her EMR that she had visited the emergency room three times within the past eight months and one visit resulted in a prolonged hospital and Intensive Care Unit stay. Following the practice’s protocol, her care team referred her to cardiac rehab. Subsequently, she has not visited the emergency room in over a year, has lost 30 pounds, no longer needs oxygen, and walks without assistance.
The size of the primary care practice can be an obstacle in implementing the PCMH model. Here, the term small is used to refer to primary care practices with only one or two physicians and an average-sized patient panel (It is not uncommon for a primary care practice with one physician to have a couple thousand patients; however, practices discussed within this paper do not have over 2,000 patients in their panel [
Regardless of the size of practices, PCMH principles encourage the use of electronic medical records to increase the efficiency of care coordination, although it is not required. This change in record keeping removes the need for medical record storage space within the practice and in turn allows for clinical space to be optimized.
Prior to fully transitioning to the PCMH model, healthcare organizations must address the issue of space. For instance, if a practice employs a care coordinator, they must be provided with space to communicate with patients in private, to perform their health assessments and individual disease coaching on the phone or in person, and to prepare plans for care, such as materials for the pre-visit huddle. It is uncommon for the traditional primary care practices to have a location for these types of private conversations and activities. Empty exam rooms or doctors’ offices may just be sufficient, especially since these conversations taking place in waiting rooms or more public areas can easily violate confidentiality standards and the Health Insurance Portability and Accountability Act of 1996.
A fully integrated EMR helps PCMHs conduct team-based care for chronic conditions by allowing members to visualize the patient instantly, through the use of problem lists, immunization history, and medication lists. However, creating an EMR that administers the principles of PCMH has been a difficult task for primary care practices in transition [
Once employed, EMRs can be used to improve patient care and therefore patient health by monitoring their health status to anticipate necessary treatments. Using the EMR, care coordinators and nurses are able to more efficiently search for specific patient types by viewing the patient’s medical record on the computerized database and to acknowledge those who require immediate attention and contact them in a timely fashion. Staff then uses population management tools in the EMR to contact these individuals and encourage them to make an appointment [
Carilion Clinic has created a structured method of administering disease management resulting in the optimization of their EMR. Their approach is to first search and then contact their patients who have a Priority One rating. Their searches are focused on patients with a chronic disease, which can be sorted in the EMR based on their conditions. Thus far, in their transition to a fully integrated EMR, Carillion Clinic has formed registries for asthma, congestive heart failure (CHF), diabetes (DM), and high blood pressure (HTN). Within each of the registries, the patient’s clinical information, such as blood pressure, last appointment date, and glycohemoglobin (A1C) is recorded. Their registries can be sorted by the necessity of care or the priority as determined by Carillion Clinic. Priority One patients are those who have at least one of three predefined health conditions determined by Carilion Clinic (Carillion developed these predefined health conditions from nationally recognized medical guidelines). An example of a Priority One patient, as defined by Carilion Clinic, would be a diabetic (DM) with an A1C over 10. Another example of a Priority One patient would be a patient who is hypertensive, or a patient with a systolic BP over 160. The Carillion staff contacts patients with these conditions as soon as possible. Between the months of March and May 2010, of the diabetic patients and hypertensive patients contacted, 43% committed to an appointment with Carillion Clinic and their care team to address their current health status (As of June 11, 2010, 63% of the appointments made have been kept). Without a fully functioning EMR with capabilities that allow Carilion Clinic and other health care providers to search for these patients efficiently, they would remain invisible to the practice and may not receive the care they need.
This paper has examined lessons learned from the implementation of PCMH at several sites, both military and civilian. PCMH demonstrations show there is still much work to be done, particularly through educating the medical community about the benefits of the model. Current PCMH demonstrations have shown that this method of care can improve the quality of life for patients, such as reducing the patient’s frequency of ER visits and hospital admissions, as well as reducing health care costs [
As with any new healthcare structure, current PCMH practices are still developing methods to improve the quality of care provided to their patients, such as care coordination, team-based care, and the use of EMR to promote care coordination. There continues to be a struggle for transitioning PCMHs in determining how to implement the guidelines that the NCQA provides, which is a concern because NCQA is the most widely recognized organization in the United States for certifying practices as PCMHs [
Healthcare professionals and organizations will be under pressure to prove the “value” of their services. In implementing PCMH, one will track HbA1c, BMI, and/or other parameters as indicators of quality, but at what point would a PCMH be qualified to receive additional payment for their improvement in the quality of patient care? Without funding for additional resources, practices will continue with the discrepancy between the current volume-based healthcare system and a system that focuses on the quality of care. The question remains of whether PCMH is the direction healthcare should go in, and many studies show that preventative care improves the quality of life [
There is no conflict of interests.
The authors would like to thank Jennifer LeFurgy for her work in organizing the Workshop on Medical Home. In addition, they would like to thank Dr. Michelle Milner for her workshop presentation on the Air Force’s Patient-Centered Medical Home. This work in part supported by HighView CRADA, W81XWH-08-2-0173, TATRC, USAMRMC.