Patient-Centered Medical Home (PCMH) Information and Resources
Patient-Centered Medical Home (PCMH) is a model of primary health care that many believe can improve health care in the U.S. by transforming how primary care is organized and delivered. The Health Resources and Services Administration (HRSA) supports and encourages all Section 330 funded health centers to become a recognized or accredited PCMH. CHAMPS has gathered the following information and resources to assist CHCs in understanding and becoming PCMHs. This webpage is designed to aid CHCs who are brand new to PCMH, those who have started the process of becoming a PCMH, and those who have already applied to become a recognized/accredited PCMH and require additional tools to successfully complete the process.
Please click or scroll down for:
History of PCMH
Definition and Goals of PCMH
PCMH Recognition/Accreditation
First Steps in Becoming a Recognized/Accredited PCMH
Introductory Guides on Becoming a PCMH
Self Assessment Tools for Determining PCMH Readiness
Tools for Building a PCMH
Templates and Samples of PCMH Policy and Procedure
PCMH Demonstration Projects, Initiatives, and Pilot Projects
Education and Training on PCMH
Reports and Articles on PCMH
PCMH Consultation Services
HISTORY OF PCMH
Following is a brief history of the PCMH movement in the U.S.
Year Event
1967 American Academy of Pediatrics (AAP) introduces the medical home concept in an
effort to improve and coordinate care for children with multiple/special needs
2001 Institute of Medicine (IOM) calls for transformation of a “fundamentally flawed”
U.S. health care system in the report Crossing the Quality Chasm
2004 In the Future of Family Medicine Project proposes a new model of care, the
“personal medical home”
2005 TransforMED is created as a subsidiary of American Academy of Family Physicians
(AAFP) to test the “New Model” which included PCMH features but no payment
reform
2006 Medical home demonstration projects within Medicare are called for in the Tax
Relief and Health Care Act, to be implemented by 2010
2007 Four organizations – American Academy of Pediatrics (AAP), American Academy
of Family Physicians (AAFP), American College of Physicians (ACP), and American
Osteopathic Association (AOA) – jointly issue the following statement of PCMH:
www.qhmedicalhome.org/resources/upload/Joint-Principles-PCMH-3-07.pdf
2007 The Patient Centered-Medical Home Collaborative is launched through an effort
by several large national companies to improve patient-physician relationships
and create a more effective and efficient model of health care delivery
2007 National Committee for Quality Assurance (NCQA) launches the tool Physician
Practice Connections/Patient-Centered Medical Home which becomes the standard
for PCMH recognition
2008 The Commonwealth Fund, Qualis Health, and MacColl Institute initiate a five-year
demonstration project to assist safety net primary care clinics in becoming
high-performing PCMHs (see PCMH Demonstration/Pilot Projects and Initiatives
section below for more information)
2009 Multiple pilot projects are in process and early findings begin to be published (see
Articles and Reports section below)
2010 The Health Resources and Services Administration (HRSA) issues Program
Assistance Letter (PAL) 2011-01 in November 2010 which describes HRSA’s
Patient-Centered Medical/Health Home (PCMHH) Initiative to support PCMH
recognition for Section 330 funded organizations
2011 The National Association of Community Health Centers (NACHC) launches its Patient
Centered Medical Home Institute (PCMHI) and issues a white paper describing
the PCMHI
2011 HRSA’s Bureau of Primary Health Care (BPHC) announces the release of the
Affordable Care Act supplemental grant opportunity for existing section 330
health centers to support the costs associated with enhancing systems and to
become PCMHs
DEFINITION AND GOALS OF PCMH
A Patient-Centered Medical Home (PCMH) is a model of primary health care that puts the patient at the center of health care. The definition of PCMH varies among the many agencies and organizations involved with PCMH development in the U.S. Following are definitions from three organizations.
American Academy of Family Physicians (AAFP)
A patient-center medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute, and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes.
American Academy of Pediatrics (AAP)
AAP developed the medical home model for delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth, including children and youth with special health care needs.
Agency for Healthcare Research and Quality (AHRQ)
The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, AHRQ defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes: patient-centered care; comprehensive care; coordinated care; superb access to care; a system-based approach to quality and safety.
Although various organizations differ on the exact definition of a PCMH most agree that PCMH is a model of primary care that encompasses at least some or all of the following functions and attributes (listed in alphabetical order):
Access to Care
Comprehensive Care
Coordinated Care
Evidence-based Care
Patient-centered Care
Payment Structures that Recognize the Value of Primary Care
Quality Care
Safe Care
Systems-based Approach to Care
Team-based Care
Joint Principles of the Patient-Centered Medical Home was issued by AAFP, AAP, ACP, and AOA in March 2007 and is available in the following document: www.qhmedicalhome.org/resources/upload/Joint-Principles-PCMH-3-07.pdf.
The principles of PCMH have evolved since the issuance of the Joint Principles of the Patient-Centered Medical Home in 2007. One significant change, at the urging of community health centers, is that nurse practitioners, not just physicians, are now recognized as a primary care clinician in a medical home.
PCMH RECOGNITION/ACCREDITATION
Health centers can become a PCMH by obtaining PCMH recognition or accreditation from one of the following three programs:
Accreditation Association for Ambulatory Health Care (AAAHC)
www.aaahc.org/eweb/dynamicpage.aspx?webcode=mha
National Committee for Quality Assurance (NCQA)
www.ncqa.org/tabid/631/default.aspx
The Joint Commission (TJC)
www.jointcommission.org/accreditation/pchi.aspx
Each of these recognition/accreditation programs has a tool for completing the process, as well as educational programs.
The document Federal Patient Centered Medical Home (PCMH) Collaborative, Catalogue of Federal PCMH Activities as of March 2011 provides an overview of HRSA’s current strategic goals, areas of activity, pilot programs, and technical assistance related to PCMH.
The HRSA PCMH Initiative, Program Assistance Letter (PAL) 2011-01 provides support and encourages health centers to gain recognition under the medical home program offered in partnership with the National Committee for Quality Assurance (NCQA).
The HRSA National Quality Recognition Initiatives Resources: Comparison Chart highlights differences between HRSA’s Accreditation initiatives and PCMH initiatives.
On March 8, 2011, the AAP, AAFP, ACP and AOA released Guidelines for Patient-Centered Medical Home Recognition Programs. The new guidelines build on the Joint Principles adopted in 2007 (see above). Included are 13 guidelines that describe important elements considered essential for effective PCMH recognition programs.
The AAP’s National Center for Medical Home Implementation provides a basic overview on their webpage Medical Home Recognition & Accreditation Programs about each of the recognition/accreditation programs.
FIRST STEPS IN BECOMING A RECOGNIZED/ACCREDITED PCMH
There are many resources available to health centers desiring to become a recognized or accredited PCMH. There are four basic steps in starting the process of becoming a PCMH:
1. Become Aware
Become aware of the PCMH model and the various recognition/accreditation programs available. You will find information about the PCMH model, recognition/ accreditation, and many other resources on this webpage. Find out if your regional/state primary care association (PCA) has any PCMH collaborative or learning team activities that your health center may participate in. Most PCAs are offering training and/or technical assistance on becoming a recognized/accredited PCMH. You may also want to become aware of the various consulting organizations that can help your health center walk through the process of becoming a PCMH (see the PCMH Consulting Services section below). Many CHCs and PCAs are hiring consultants to help them through the PCMH process.
2. Assess Your Readiness
Every health center should perform a basic assessment of readiness before applying to a PCMH recognition or accreditation program. There are several tools available to assess your health centers readiness and are listed in the Self-Assessment Tools for Determining PCMH Readiness section below.
3. Choose a Recognition/Accreditation Program and Necessary Support Services
Decide which recognition/accreditation program will best fit your health center. Depending on which program you choose, you may also need to decide which level and year of certification you would like to aim for. Criteria for choosing a recognition/accreditation program include the following: Medicaid and/or Medicare reimbursement and incentives in your state that may be tied to a specific recognition/accreditation program; HRSA support and assistance for each program; applicability to frontier, rural, and/or isolated areas; accreditation that your health center already holds or may be applying for. This is also a good time to determine if you will participate in any collaborative or learning team activities, and/or if you will hire a consultant to help you through the process.
4. Prepare for a Rigorous Process and Form a Core Team
It often takes six or more dedicated months for a health center to complete a PCMH application process. There are usually many systems, processes, policies, and teams that a health center will need to develop to pass a PCMH program. Prepare your entire health center for this process and form a core team that will be committed to your health center gaining PCMH status.
INTRODUCTORY GUIDES TO BECOMING A PCMH
The Board’s Role to Support Patient-Centered Medical Homes
NACHC
Introduction to PCMH for CHC Boards that presents an overview of PCMH and changes that a health center must make to transform to a PCMH
2011
NCQA’s Patient-Centered Medical Home 2011
NCQA
Eleven-page document that describes the NCQA PCMH program and the six standards and must-pass elements
2011
NCQA Patient-Centered Medical Home Recognition Process
NCQA
Three-page document that provides instructions on how to start the NCQA PCMH Recognition process
2011
Providing Underserved Patients with Medical Homes: Assessing the Readiness of Safety-Net Health Centers
www.commonwealthfund.org/Publications/Issue-Briefs/2010/May/Providing-Underserved-Patietns-with-Medical-Homes.aspx
The Commonwealth Fund
A brief that explores the potential of primary care safety-net health centers to become PCMHs including characteristics of safety-net health centers relevant to PCMH transformation, areas for improvement, and a set of strategies to assist health centers in becoming PCMHs
2010
Obtaining Patient-Centered Medical Home Recognition: A How to Manual
www.pcdc.org/assets/pdf/pcdc-pcmh-manual-2009.pdf
Primary Care Development Corporation (PCDC)
Step-by-step guide to assist safety-net providers in applying for and obtaining recognition as a medical home through NCQA
2009
SELF-ASSESSMENT TOOLS FOR DETERMINING PCMH READINESS
There are several tools available at no cost that CHCs can use to determine if they are ready to embark on the recognition/accreditation process of becoming a PCMH. Following are some commonly used self-assessment tools.
Medical Home Implementation Quotient Assessment (MHIQ)
www.transformed.com/mhiq/welcome.cfm
TransforMED
Quick and easy tool that helps practices determine where they stand on the journey to becoming a PCMH by answering approximately 12 questions and receiving a score that allows comparison to the NCQA Standards
NCQA 2011 Medical Home Assessment Tool
www.pcdc.org/resources/patient-centered-medical-home/pcdc-pcmh/ncqa-2011-medical-home.html
Primary Care Development Corporation (PCDC)
Guides primary care practices through the NCQA medical home survey process to assess how the practice compares to the PCMH NCQA 2011 Standards including the use of EHRs, patient/provider communication, data outcomes, workflow redesign, and care management and coordination
Patient-Centered Medical Home Assessment (PCMH-A), Public Copy
www.qhmedicalhome.org/safety-net/upload/PCHM-A_SNMHI_092710.pdf
MacColl Institute for Healthcare Innovation
Survey designed to help practices move toward state-of-the-art in delivering PCMH care by using results from the survey to identify areas for improvement
PCMH Checklist
www.aafp.org/online/en/home/membership/initiatives/pcmh.html
American Academy of Family Physicians (AAFP)
Quick and easy tool designed to help primary care practices determine how close they are to being a PCMH
TOOLS FOR BUILDING A PCMH
Building Your Medical Home Toolkit
www.pediatricmedhome.org/
National Center for Medical Home Implementation, American Academy of Pediatrics (AAP)
Free toolkit that supports development and/or improvement of a pediatric medical home by preparing practices to apply for and potentially meet the NCQA recognition requirements, including a crosswalk between the toolkit building blocks and the NCQA “must pass” elements
CHC Core Requirements, NCQA Recognition Elements, and Meaningful Use Requirements Crosswalk
2011 Crosswalk
Colorado Community Health Network (CCHN)
Excel spreadsheet that compares NCQA PCMH recognition, Meaningful Use, and CHC core requirements to help CHCs plan, organize and implement processes that satisfy requirements for multiple purposes
Implementation Guides
www.qhmedicalhome.org/safety-net/publications.cfm
Qualis Health
Eight guides available on the Safety Net Medical Home Initiative change concepts including Empanelment, Team-Based Care, Patient-Centered Interactions, Engaged Leadership, QI Strategy, Enhanced Access, Care Coordination, and Organized Evidence Based Care
Medical Home Builder
www.medicalhomebuilder.org/about
American College of Physicians
Includes modules, user-generated best practice videos, webinars, assessment tools and a resource library for organizations that buy annual licenses based on the size of their practice
Meaningful Use Requirements
NCQA PCMH 2011 and CME Stage 1 Meaningful Use Requirements
NCQA
Assessment tool that allows practices to compare side-by-side the core elements of the NCQA 2011 PCMH Standards and the CMS Stage 1 Meaningful Use Requirements
PCMH /Meaningful Use (MU) Gap Analysis and PCMH/MU ROI Tools
www.chcanys.org/index.php?src=gendocs&ref=PCMH/MU%20Tools&category=Health%20Care%20Reform
PCDC and Community Health Care Association of New York State (CHCANYS)
Tools developed for CHCs to analyze gaps between PCMH and Meaningful Use (MU) and to calculate ROI (return on investment) for PCMH and MU incentives
Transformation Series Workbooks
www.transformed.com/publications.cfm
TransforMED
Series of five workbooks that provide concise, step-by-step information on health care delivery that is instrumental in transforming practices to PCMHs including scope of change, care coordination, care management, access, and the clinical team
Videos on PCMH, Integrated Behavioral Health, and Office Efficiencies
http://www.clinica.org/index.php
Clinica Family Health Services
Videos from a CHC in Colorado (Clinica Family Health Services) with NCQA, Level 3 PCMH Recognition on the CHC's model of health care
TEMPLATES/SAMPLES OF PCMH POLICIES AND PROCEDURES
To view and download samples of policies/procedures and PCMH recognition documentation, click on this CHAMPS webpage:
www.champsonline.org/ToolsProducts/CrossDiscResources/PCMH/PCMHPandPs.html
If your health center has any policies, procedures, or other documents to share that would help other Region VIII CHCs in adopting PCMH standards, please contact Shannon Kolman, CHAMPS Clinical Programs Coordinator, at Shannon@champsonline.org or 303-867-9583.
PCMH DEMONSTRATION PROJECTS, INITIATIVES, AND PILOT PROJECTS
Comprehensive Primary Care Initiative
http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/cpci/
Centers for Medicare & Medicaid (CMS), Center for Medicare and Medicaid Innovation
CMS initiative, announced September 28, 2011, will foster collaboration between public and private health care payers to strengthen primary care by testing a service delivery model, which includes risk-stratified care management, access and continuity, planned care, patient and caregiver engagement, and coordination of care, and by testing a payment model that will include a case management fee paid to selected primary care practices
Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Project
http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/fqhc/
CMS
Demonstration project operated by CMS in partnership with HRSA aims to show how the PCMH model can improve quality of care, promote better health, and lower costs by helping FQHCs invest in patient care and infrastructure as described in the following news release
http://www.hhs.gov/news/press/2011pres/10/20111024a.html
NACHC Patient Centered Medical Home Institute (PCMHI)
www.nachc.com/mhresources.cfm
NACHC
Aims to build capacity and infrastructure at the state, regional, and national levels to document and improve outcomes in quality, cost, patient and community engagement, and population health by developing state-based infrastructure in support of local health system transformation
Patient-Centered Outcomes Research Institute (PCORI)
http://www.pcori.org/about/
Created to conduct research to provide information about best available evidence to help patient and providers make more informed decsions through research funding opportunities which are posted on the following webpage
http://www.pcori.org/funding-opportunities/
Safety Net Medical Home Initiative
www.qhmedicalhome.org/safety-net/index.cfm
Commonwealth Fund, Qualis Health, and MacColl Institute
Five-year demonstration project initiated in 2008 to assist safety net primary care clinics in becoming high-performing PCMHs through partnerships between safety net providers and community stakeholders with five Regional Coordinating Centers being selected to participate with each including 12-15 safety net clinics in their area:
Colorado Community Health Network
Executive Office of Health and Human Services & Massachusetts League of Community Health
Centers
Idaho Primary Care Association
Oregon Primary Care Association and CareOregon
Pittsburgh Regional Health Initiative
State Pilot Projects in the U.S.
www.pcpcc.net/pcpcc-pilot-projects
Patient-Centered Primary Care Collaborative (PCPCC)
Listing of state PCMH projects, in safety net and multi-payer sites, across the U.S. listed by project, state, and start date
EDUCATION AND TRAINING ON PCMH
Archived Webinars
www.pcpcc.net/
PCPCC
Free webinar replays and slides for a multitude of presentations on PCMH including infrastructure, approaches to coordinated care, health information technology, behavioral health integration, training the workforce, and a PCPCC website walkthrough
Change Concepts
www.qhmedicalhome.org/safety-net/change-concepts.cfm
Qualis Health
Free guides, slide presentations, and videos on eight change concepts including Empanelment, Team-Based Care, Patient-Centered Interactions, Engaged Leadership, QI Strategy, Enhanced Access, Care Coordination, and Organized Evidence Based Care
NCQA Recognition Learning Series
www.healthteamworks.org/medical-home/ncqalearning.html
HealthTeamWorks
Free five-module webinar series with in depth descriptions of the NCQA recognition requirements
NCQA Recognition Training Programs
www.ncqa.org/tabid/109/Default.aspx
NCQA
Free links to slide presentations including Getting On Board, Standards 1-3, and Standards 4-6 presented by NCQA
The National Medical Home Summit
www.medicalhomesummit.com/
Health Care Conference Administrators
The ongoing hybrid conference/internet events includes a post-conference webinar series. The February 27-29, 2012 National Medical Home Summit includes an in-depth training program on medical home issues and strategies, available live online and archived for six months. CHAMPS members can view the live and archived webcast at discounted group rates: $295 per person for groups of 3-5 members or $195 each for groups of 6 or more. Standard registration fees for live and archived events start at $595 each for groups of 5 or more and $795 for individual registration. See the following webpage for registration information http://medicalhomesummit.com//registration.php. Contact Shannon Kolman, CHAMPS Clinical Programs Director, at Shannon@champsonline.org or 303-867-9583, to receive instructions on how to receive the CHAMPS member discount and save hundreds on registration for your health center.
REPORTS/ARTICLES ON PCMH
Results from 2010-11 Readiness for Meaningful Use of HIT and Patient-Centered Medical Home Recognition Survey
http://www.rchnfoundation.org/images/FE/chain207siteType8/site176/client/Readiness%20%20Databook%20final%2011%2001%2011.pdf
Geiger Gibson/RCHN Community Health Foundaton Research Collaborative, Policy Research Brief #27
November 3, 2011
Will the Patient-Centered Medical Home Transform the Delivery of Health Care? Timely Analysis of Immediate Health Policy Issues
www.nachc.com/client/UrbanInstitutePCMHAnalysisAugust2011.pdf
Urban Institute and Robert Wood Johnson Foundation
August 2011
Developing Federally Qualified Health Centers into Community Networks to Improve State Primary Care Delivery Systems
www.commonwealthfund.org/Publications/Fund-Reports/2011/May/Developing-Federally-Qualified-Health-Centers.aspx
The Commonwealth Fund
May 2011
Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details
http://urban.org/publications/412338.html
Urban Institute
May 2011
The Evolution of the Primary Care Medical Home
www.nachc.com/magazine-article.cfm?MagazineArticleID=185
David Stevens, MD, NACHC Community Health Forum
Winter/Spring 2011
Community-Centered Health Homes: Bridging the Gap Between Health Services and Community Prevention
www.preventioninstitute.org/component/jlibrary/article/id-298/127.html
Prevention Institute
February 2011
Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the United States
www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf
PCPCC
November 2010
Family Medicine: Preparing for a High-Performance Health Care System
www.qhmedicalhome.org/safety-net/upload/Karen-Davis-Article-March-2010.pdf
K. Davis, PhD, and K. Stremikis, MPP, JABFM, Vol. 23 Supplement
March-April 2010
Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home
www.annfammed.org/cgi/content/abstract/8/Suppl_1/S2
K. C. Stange, MD, PhD, et al., Annals of Family Medicine, Vol. 8, Supplement 1
2010
Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation
www.ajmc.com/media/pdf/AJMC_09sep_ReidWEbX_e71toe87.pdf
R.J. Reid, et al., The American Journal of Managed Care, Vol. 15, No. 9, Pg. 71-87
September 2009
Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home
www.annfammed.org/cgi/reprint/7/3/254
P. A. Nutting, MD, MSPH, et al., Annals of Family Medicine, Vol. 7, No. 3
May/June 2009
Proof in Practice
www.pcpcc.net/files/Pilot-Guide_09.pdf
Patient-Centered Primary Care Collaborative (PCPCC)
2009
PCMH CONSULTATION SERVICES
Please note, CHAMPS does not endorse any of the following consultation services. This listing contains services that are being utilized by CHCs and private primary care practices throughout the nation. It is wise when considering a consultation service to inquire about other similar clients and ask to speak to those clients about the work performed and the level of satisfaction.
Arcadia Solutions
www.arcadiasolutions.com
Center for Medical Home Improvement (CMHI)
www.medicalhomeimprovement.org/medical-home/developments.html
HealthTeamWorks
www.healthteamworks.org/medical-home
i2iSystems
www.i2isys.com/patient-centered-medical-home.htm
Phytel
www3.phytel.com/
Primary Care Development Corporation (PCDC)
www.pcdc.org/resources/patient-centered-medical-home/
Qualis Health
www.qhmedicalhome.org/
TransforMED
www.transformed.com/transformed.cfm
