The Patient-Centered Medical Home - American College of ...

The Patient-Centered Medical Home:
What, Why, Where, When…and How
American College of Osteopathic Internists
Annual Convention & Scientific Sessions
October 2012
Orlando, FL
Michael S. Barr, MD, MBA, FACP
Senior Vice President
Medical Practice, Professionalism & Quality
mbarr@acponline.org
202-261-4531

Goals for Presentation
• Building the case for change (What & Why)
• Does the PCMH fit into the future of health
care? What about the “neighborhood”?
(Where & When)
• What are the tactics to achieve three-part aim
(aka Triple Aim)? (How)
• How can practices move towards the PCMH?
(How)

↑Access ↑Quality ↓Cost
Desired
Future

QUALITY: PATIENT-CENTERED, TIMELY CARE
Waiting Time to See Doctor When Sick or Need Medical Attention,
Among Sicker Adults, 2008
Percent of adults who could get an appointment on the same or next day
when sick or needed medical attention
100
75
50
25
0
80
71
62 61 59
NETH NZ FRA UK GER AUS US CAN
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or
had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New
Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
53
43
EXHIBIT 16
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 6
36

EQUITY: HEALTHY LIVES
144 144
Coronary Heart Disease and Diabetes-Related Mortality,
by Race/Ethnicity and Education Level, 2006
Age-adjusted mortality per 100,000 population
250
200
150
100
50
0
Coronary heart disease mortality
188
114
101
Total White Black Hispanic Less than
high
school
71
High
school
graduate
28
At least
some
college
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 14
250
200
150
100
50
0
74
Diabetes-related mortality
68
130
86
61
Total White Black Hispanic Less than
high
school
Data: National Vital Statistics System—Mortality (retrieved from DATA2010 at http://wonder.cdc.gov/data2010).
41
High
school
graduate
16
At least
some
college

ACCESS: PARTICIPATION
5
6
Access Problems Because of Costs, 2010
Percent of adults who had any of three access problems* in past year because of costs
50
25
0
10 10 11
13 14 15
UK NETH SWE SWIZ NOR FRA NZ CAN AUS GER US
* Did not get medical care because of cost of doctor’s visit; skipped medical test, treatment, or follow-up because of cost;
or did not fill Rx or skipped doses because of cost.
AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; NOR=Norway;
SWE=Sweden; SWIZ=Switzerland; UK=United Kingdom; US=United States.
Data: 2010 Commonwealth Fund International Health Policy Survey.
22
25
33
EXHIBIT 16
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 15

ACCESS: PARTICIPATION
CA
OR
WA
NV
ID
AZ
UT
AK
MT ND
WY
NM
CO
Percent of Adults Ages 19–64 Uninsured by State
1999–2000 2009–2010
HI
SD
NE
TX
KS
OK
MN
IA
MO
AR
LA
WI
IL
MS
IN
TN
MI
AL
KY
OH
G
A
WV
SC
FL
NC
23% or more
19%–22.9%
14%–18.9%
Less than 14%
Data: U.S. Census Bureau, 2000–01 (revised) and 2010–11 Current Population Survey ASEC Supplement.
PA
VA
VT NH
NY
ME
MA
RI
CT
NJ
DE
MD
DC
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 16
CA
OR
WA
NV
ID
AZ
UT
AK
MT ND
WY
NM
CO
HI
SD
NE
TX
KS
OK
MN
IA
MO
AR
LA
WI
IL
MS
IN
TN
MI
AL
KY
OH
G
A
WV
SC
FL
PA
VA
NC
VT NH
NY
ME
MA
RI
CT
NJ
DE
MD
DC

ACCESS: PARTICIPATION
CA
OR
Post-Reform: Projected Percent of Adults Ages 19–64 Uninsured by State
WA
NV
ID
AZ
UT
AK
MT ND
WY
NM
CO
2009–2010 2019 (estimated)
HI
SD
NE
TX
KS
OK
MN
IA
MO
AR
LA
WI
IL
MS
IN
TN
MI
AL
KY
OH
G
A
WV
SC
FL
PA
VA
NC
NY
23% or more
19%–22.9%
14%–18.9%
VT NH
ME
8%–13.9%
Less than 8%
Data: U.S. Census Bureau, 2010–11 Current Population Survey ASEC Supplement; estimates for 2019 by Jonathan Gruber
and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund.
MA
RI
CT
NJ
DE
MD
DC
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 18
CA
OR
WA
NV
ID
AZ
UT
AK
MT ND
WY
NM
CO
HI
SD
NE
TX
KS
OK
MN
IA
MO
AR
LA
WI
IL
MS
IN
TN
MI
AL
KY
OH
G
A
WV
SC
FL
PA
VA
NC
VT NH
NY
ME
MA
RI
CT
NJ
DE
MD
DC

Florida Data 2011
http://statesnapshots.ahrq.gov/snaps11/

Florida Data 2011

Florida Data 2011

Florida Data 2011

http://www.commonwealthfund.org/Maps-and-Data/State-Data-Center/State-Scorecard.aspx

http://whynotthebest.org

EFFICIENCY
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
1980
International Comparison of Spending on Health, 1980–2009
1982
Average spending on health
per capita ($US PPP*)
1984
United States
Canada
Germany
France
Australia
United Kingdom
1986
1988
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2011 (database), version 6/2011.
1990
1992
1994
1996
1998
2000
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
2002
2004
2006
2008
18
16
14
12
10
8
6
4
2
0
1980
1982
1984
Total expenditures on health
as percent of GDP
1986
1988
1990
1992
1994
1996
1998
United States
France
Germany
Canada
United Kingdom
Australia
2000
2002
2004
2006
2008
25

Illness / Wellness Pyramid – 2010 CareFirst Experience
80% of
admissions
were for
members in
bands 1 and 2
Advanced / Critical
Illness
BAND 1
Multiple Chronic
Illnesses
BAND 2
At Risk
BAND 3
Stable
BAND 4
Healthy
BAND 5
Source: CareFirst Health Care Analytics
Percent of
Population
Percent of
Cost
PMPM
Cost
Illness
Burden
Range
3% 37% $4,212 ≥ 5.0
8% 22% $1,106 2.00-4.99
12% 18% $577 1.00-1.99
27% 17% $246 0.25-0.99
50% 6% $57 0-0.24
26

Reasons for Growth in Healthcare
Spending (MedPac, March 2012)
Technology: introduction/diffusion/expansion
Price: lack of transparency; lack of competition
Competition/Regulation: markets with provider
consolidation/less competition leads to excess
bargaining power
Health Insurance: insulation to cost; lack of
knowledge about comparative effectiveness
Income/Wealth/Demographics: increase in
national income & wealth lead to more spending
MedPac Report to Congress March 2012

Performance on indicators of health system efficiency remains
especially low, with the U.S. scoring 53 out of 100 on measures
that gauge the level of inappropriate, wasteful, or fragmented
care; avoidable hospitalizations; variation in quality and costs;
administrative costs; and use of information technology.
Lowering insurance administrative costs to benchmark country
rates could alone save up to $114 billion a year, or $55 billion if
such costs were lowered to the level in countries with a mixed
private–public insurance system, like the U.S. has.
--Why Not the Best? Results from the National Scorecard on U.S.
Health System Performance, 2011

“We are at a crossroads…
…one road leads to
hopelessness and
despair;
…the other leads to total
extinction.
Let us pray that we
choose wisely.”
-- Woody Allen

Strategy without tactics
is the slowest route to victory.
Sun Tzu – Chinese Military General
Tactics without strategy
is the noise before defeat.

Strategy
Berwick, Nolan & Whittington; Health Affairs 2008
Reduce Per
Capita Costs
Improve
Health of
Populations
Improve the
Experience
of Care
Three Part Aim

National Quality Strategy
March 2011
1. Making care safer by reducing harm.
2. Ensuring that each person and family are engaged.
3. Promoting effective communication & coordination.
4. Promoting the most effective prevention and
treatment practices for the leading causes of
cardiovascular disease.
5. Working with communities to promote wide use of
best practices to enable healthy living.
6. Making quality care more affordable for individuals,
families, employers, and government by developing
and spreading new health care delivery models.
http://www.healthcare.gov/law/resources/reports/quality03212011a.html

Tactics PCMH/
PCMH-N
Accountable
Care Models
Culture
Improve
Experience
of Care
Improve
Health of
Populations
Reduce Per
Capita Costs
Payment
Health IT

PCMH Time Line
1967
-AAP Introduces
“medical home”
concept
1992
-AAP publishes
first policy paper
1980
-Dr. Cal Sia, Peds gets
Hawaii to adopt MH
2002
-AAP updates
policy paper
2006
ACP AMH
TRHCA 2006
2004
AAFP
- FFM
2009
Advanced
Primary Care
2008
NCQA-
PCC-
PCMH
2007
Joint
Principles
PCMH
2011 CMS
Comprehensive
Primary Care
2010
Affordable
Care Act

March 2007:
AAFP, AAP, ACP, AOA Release
Joint Principles of PCMH

The Joint Principles of the PCMH
• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated
and/or integrated
• Quality and safety
• Enhanced access to care
• Payment to support the PCMH
http://www.acponline.org/running_practice/p
cmh/demonstrations/jointprinc_05_17.pdf
Team-based care:
NP/PA
RN/LPN
Medical Assistant
Office Staff
Care Coordinator
Nutritionist/Educator
Pharmacist
Behavioral Health
Case Manager
Social Worker
Community resources
DM companies
Others…

Collaboration Among Societies
March 2009: Guidelines for PCMH Demonstration
Projects
November 2010: Joint Principles for Accountable
Care Organizations
December 2010: Joint Principles for the Medical
Education of Physicians in Preparation for Practicing
in the PCMH
February 2011: Guidelines for PCMH Recognition
and Accreditation Programs
Working On… Joint Guidelines for Integrating
Mental Health/Behavioral Health into Primary Care

2007
Patient-Centered Primary Care
Collaborative Formed

Six
Collaborative
Centers:
www.pcpcc.net
Overview of PCPCC
Activities
• Center for Multi-Stakeholder
Demonstrations
• Center to Promote Public Payer
Implementation
• Center for Employer Engagement
• Center for eHealth
• Center for Consumer Engagement
• Center for Accountable Care

Current Demos
(Per PCPCC Website)
http://pcpcc.net/pcpcc-pilot-projects (as of 7/31/12)

Recognition & Accreditation Programs
January 2008: NCQA Releases PPC-PCMH
Recognition Program
2009: Accreditation Association for Ambulatory
Health Care – Medical Home Program
September 2010: Joint Commission announces
Primary Care Home Initiative
December 2010: URAC Releases Patient-Centered
Health Care Home Tool Kit
January 2011: NCQA Releases PCMH 2011
May 2011: Joint Commission releases PCH Initiative

http://www.ncqa.org/LinkClick.aspx?fileticket=MYvjUN6K3Ik%3d&tabid=
631&mid=2435&forcedownload=true

NCQA Standard Must Pass Element Meaningful Use Correlate
Identify & Manage
Populations
Use Data for Population
Management
-Use clinical decision
support
-Generate lists of patients
Plan & Manage Care Care Management -Medication reconciliation
-Generate reminders
Provide Self-Care Support &
Community Resources
Track & Coordinate Care Referral Tracking & Followup
Measure & Improve
Performances
NCQA vs. Meaningful Use
Support Self-Care Process -View/download/transmit
-Send secure messages
Implement Continuous
Quality Improvement
-Provide summary of care
for transitions
-Record team members
-Incorporate imaging
results
-Report on Clinical Quality
Measures (CQMs)

Comprehensive Primary Care Initiative
• CPCi is a multi-payer initiative fostering
collaboration between public and private health
care payers to strengthen primary care.
• Medicare will work with commercial and State
health insurance plans and offer bonus payments
to primary care doctors who better coordinate
care for their patients.
• Primary care practices that choose to participate
in this initiative will be given resources to better
coordinate primary care for their Medicare
patients.

Seven Regions Selected
• Arkansas: Statewide (4 Payers)
• Colorado: Statewide (9 Payers)
• New Jersey: Statewide (5 Payers)
• New York: Capital District-Hudson Valley Region
(6 Payers)
• Ohio and Kentucky: Cincinnati-Dayton Region (10
Payers)
• Oklahoma: Greater Tulsa Region (3 Payers)
• Oregon: Statewide (7 Payers) Read More

CPCi Practice Milestones
1. Create an annual budget
2. Provide care management for high-risk patients
3. Provide 24/7 access to the medical record
4. Assess & improve patient experience of care
5. Use data to guide improvement in care at the provider/care team
level
6. Demonstrate active engagement and care coordination across the
medical neighborhood
7. Improve patient shared decision-making capacity
8. Participate in market-based learning community (This would be
unique to the CPCi and organized by them)
9. Attest to the Stage 1 Meaningful Use EHR Incentive Program
requirements

Payment Model for CPCi
• The payment model includes a monthly care
management fee paid to the selected primary care
practices on behalf of their fee-for-service Medicare
beneficiaries
• In years 2-4 of the initiative, the potential to share in
any savings to the Medicare program.
• Practices will also receive compensation from other
payers participating in the initiative, including private
insurance companies and other health plans, which will
allow them to integrate multi-payer funding streams to
strengthen their capacity to implement practice-wide
quality improvement.

100
75
50
25
0
64
Widespread Support for Medical Homes
Percent reporting importance of having one place/doctor
responsible for primary care and coordinating care
93 93 93 92 93 94 94
21
89
29
29 26 24
30
41
30
72
52
64 67 69
Total NE NC South West Dem Rep Ind
NE=Northeast; NC=North–Central; Dem=Democrat; Rep=Republican; Ind=Independent.
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.
Important
Very important
U.S. region Political affiliation
59
63
THE
COMMONWEALTH
FUND

Project Hosp ER Visits Quality Pt
Experience
Group Health
Cooperative (WA)
-6% (all)
-13% (ACSC)
Geisinger (PA) -18% (all)
-36% (re-ad)
-29% Improved Improved in
5 / 7 scales
NDP (national) NA NA Improved
Community Care of
North Carolina*
Colorado Medical
Homes for Children*
Intermountain (UT)* -5% (all)
-19% (c.dz)
Total $ per
patient/yr
-$120
NA NA NA -7% (+5% to -18%)
-40% NA Improved
asthma, DM
Slightly
worse (NS)
NA -$516
(Not Stat Significant)
*Practice Rev
+2% to 12%
-18% -16% NA NA -$169 (all)
-$530 (c. dz)
0% (all)
-7% (c.dz)
NA NA -$640
North Dakota BCBS* -6% -24% NA NA -$530
Vermont Blueprint* -11% -12% NA NA -$215
Slide courtesy of Dr. Asaf Bitton. See also:
Bitton A, Martin C, Landon B. “A National Survey of PCMH Demonstrations. JGIM. June 2010.
*Not peer reviewed ACS= ambulatory care sensitive conditions c dz = chronic disease
NS = not statistically significant re-ad = readmissions

Horizon Blue Cross Blue Shield (NJ)
• Quality Measures
• 8% higher rate in improved diabetes control (HbA1c)
• 6% higher rate in breast cancer screening
• 6% higher rate in cervical cancer screening
• Cost and Utilization Indicators
• 10% lower cost of care (per member per month)
• 26% lower rate in emergency room visits
• 25% lower rate in hospital readmissions
• 21% lower rate in hospital inpatient admissions
• 5% higher rate in the use of generic prescriptions
http://www.horizon-bcbsnj.com/news_room/news_releases/article.html?id=33878

Group Health Cooperative
• $10 PMPM reduction in total costs; total PMPM cost $488
for PCMH patients vs. $498 for control patients (p=.076).
• 16% reduction in hospital admissions (p

HealthPartners Medical Group
BestCare PCMH Model (MN)
• 39% decrease in emergency department visits
and 24% decrease in hospital admissions per
enrollee between 2004 and 2009.
• Overall costs for enrollees in HealthPartners
Medical Group decreased from being equal to
the state average in 2004 to 92% of the state
average in 2008, in a state with costs already
well below the national average.

Some Additional Findings To Date…
• Medicaid: Improved access to care, reduced
PMPM/PMPY costs, decreased ER and
inpatient utilization, greater use of evidencebased
primary care
• Access to care through visits outside of regular
hours and same day access reduced
emergency department use
• Improved patient and clinician satisfaction
Takach, M. 2011. Reinventing Medicaid: State Innovations to Qualify And Pay For
Patient-Centered Medical Homes Show Promising Results. Health Affairs. 30(7):1325-1334.
Bodenheimer, T., H. Pham. 2010. Primary Care: Current Problems and Proposed Solutions. Health Affairs. 29(5):799–805.
Reid, R., P. Fishman, O. Yu, T. Ross, J.T. Tufano. 2009. Patient-Centered Medical Home Demonstration: A prospective,
quasi-experimental, before and after evaluation. American Journal of Managed Care. 15(9), e71-e87.

www.pcmh.ahrq.gov

Infrastructure
(Integrated
Network/CI ACO)
Community
Neighbor
PCMH

• First contact
• Comprehensive
• Coordinating
• Integrated with
behavioral
health/mental heath
• Wellness &
Preventative care
PCMH

Care Coordination
“Effective care coordination…requires not
only full access to all the necessary clinical
information…but also a willingness by all the
physicians [and their teams] involved…to
participate in collaborative decision making.”
-Elliott Fisher, NEJM 2008

Gaps in Care Coordination
• Primary care and specialists:
– No information sent to Peds specialist 49% of time; no feedback to
primary care 55% of time
• Emergency Department
– 30% of adults indicated regular physician not informed about visit
• Hospital
– 33% of adults with chronic condition did not have follow-up plans
post hospital discharge
– 3% of primary care physicians discussed discharge plans with hospital
physicians
– 66% of time primary care follow-up post discharge was done without
a hospital discharge summary
Bodenheimer, T: Coordinating Care – A Perilous Journey through the Health Care System. NEJM 2008;358:10

Nearly Half of U.S. Adults Report Failures to Coordinate Care
Percent U.S. adults reported in past two years:
Your specialist did not receive basic
medical information from your
primary care doctor
Your primary care doctor did not
receive a report back from a specialist
Test results/medical records were not
available at the time of appointment
Doctors failed to provide important
medical information to other doctors
or nurses you think should have it
No one contacted you about
test results, or you had to call
repeatedly to get results
Any of the above
13
15
19
21
25
47
0 20 40 60
Source: S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization:
A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008).
THE
COMMONWEALTH
FUND

Fragmentation
• Typical primary care physician relates to
229 other physicians in 117 practices for
Medicare FFS beneficiaries
Pham, H et al: Ann Intern Med February 17, 2009 150:236-242

Teams
• Wikipedia definition: A team comprises a group of
people linked in a common purpose. Teams are
especially appropriate for conducting tasks that
are high in complexity and have many
interdependent subtasks.
• Interdependent team:
– no significant task can be accomplished without
the help of any of the members;
– within that team members typically specialize in
different tasks, and
– the success of every individual is inextricably bound to the success
of the whole team. No football player, no matter how talented,
has ever won a game by playing alone.
Adapted from: http://en.wikipedia.org/wiki/Team

The Patient-Centered Medical Home
Neighbor

Typology of Clinical Roles -
Specialists
• Cognitive consultation
– Provide diagnostic or therapeutic advice
• Procedural consultation
– Perform a technical procedure to aid diagnosis, cure a
condition, identify/prevent new conditions, palliate
• Co-manager with shared care
– Long-term management with primary care physician
• Co-manager with principal care
– Assume total responsibility for long-term management
• Primary care physician
– Provides a medical home for a group of patients
Forrest, Christopher: Arch Int Med 2009

PCMH Neighbor Attributes
• Provide effective bidirectional communication with a
focus on care coordination and information sharing
with the PCMH
• Engage in timely and appropriate
referrals/consultations
• Support patient-centered care co-management
• Establish care coordination agreements that:
– Define roles/responsibilities/expectations
– Provide specific parameters for secondary referrals,
admissions, emergencies
• Align incentives
• Explore a PCMH-N recognition process

Good Neighbors?

%
60
50
40
30
20
10
0
Percentage of Services Obtained at Retail Clinics
48 47
New illness
or symptom
Prescription
renewal
23
Source: Center for Studying Health System Change 2007 Health Tracking Household Survey, April 2007–January 2008
Publication: H. T. Tu and G. R. Cohen, Checking Up on Retail-Based Health Clinics: Is the Boom Ending?,
The Commonwealth Fund, December 2008.
18
Vaccination Care for
ongoing
chronic
condition
Notes: Categories are not mutually exclusive; respondents were able to select multiple categories.
14
Physical
exam for school,
camp, or
employment
5
Other
THE
COMMONWEALTH
FUND

%
80
60
40
20
0
Reasons for Choosing Retail Clinics
Over Other Health Providers
64
Clinic hours were
more convenient
than another
source of care
62
Location was
more convenient
than another
source of care
Source: Center for Studying Health System Change 2007 Health Tracking Household Survey, April 2007–January 2008
Publication: H. T. Tu and G. R. Cohen, Checking Up on Retail-Based Health Clinics: Is the Boom Ending?,
The Commonwealth Fund, December 2008.
53
Did not have
to make an
appointment
for a retail clinic
Notes: Categories are not mutually exclusive; respondents were able to select multiple categories.
48
Cost was
lower than
another source of
care
34
Did not have a
usual source
of care
THE
COMMONWEALTH
FUND

Community

Patient-Centered, Core of Team-Based Physician-Guided Care
Care
Practice Family
Team
Physician Patient
Adapted from:
Defining Primary Care: An Interim Report, Institute of Medicine 1994

http://permanent.access.gpo.gov/gpo16811/acsbr10-17.pdf

http://labs.slate.com/articles/food-deserts-in-america/

http://iom.edu/~/media/Files/Activity%20Files/PublicHealth/
PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf

-Atul Gawande; NCQA Quality Awards 2012

Infrastructure
(Health System,
Integrated
Network/CI/ACM)

Integrated Delivery System
Practice
Team
Physician
Practice
Team
Physician
Patient
Physician
Practice
Team
Accountable Care Model
Practice
Physician Team
Clinical Integration Independent
Practice Assoc.

Building the Model

Pyramid to Peak Performance
Service
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency
Technology

The first rule of any technology used in a business
is that automation applied to an efficient operation
will magnify the efficiency. The second is that
automation applied to an inefficient operation will
magnify the inefficiency.
Bill Gates
http://www.brainyquote.com/
640K ought to be enough for
anybody.
Bill Gates

Service
Technology
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency

Personnel/Training/Competency
• Right number, skill sets, competencies
– Clinical & administrative
– Cross-trained
• Assessment of readiness for change
• Recognize potential “threats” to staff
• Assess satisfaction with job activities
• Remove barriers to working at level of training

Organization/Infrastructure
• Identify any cultural issues that impede teamwork
and collaboration
• Review hierarchy and org chart
• Introduce team-huddles
• Improve communication
• Review facility layout and lines of sight

Workflow/Logistics
• Evaluate work flow of common processes as well as
uncommon yet critical pathways
• Eliminate extraneous steps, layered “solutions” and
misapplied technology
• Consider the functionality of well-implemented
technology to assist clinicians, staff, patients &
families

Technology
• Right product(s)
• Right prep & training
• Right implementation
• Right support
• Right optimization
• Right maintenance

Service
• Organized, pro-active, responsive, accountable and
accessible
• Culturally competent
• Addresses health literacy/numeracy
• Focused on quality & safety
• Addresses needs of individuals and the population
• Incorporates patient preferences, stated
needs/desires in formulating care strategies and
follow-up
• Uses health information technology to facilitate care

Teambased
practice
Improves
Care
Chart
Organization

Patient/Family
Communication
Medication
Management
Chart
Lab/Test
Tracking
Referral Tracking

Labs
Radiology
Referral
Requests
Suppliers
Hospitals
Rx
Clinicians
Patients
Family
Clinicians
Families
/Pts
Home
Health
Hospitals
Rx
Vendors
&
Suppliers
Payers/
Prior
Auths

Service
Technology
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency

Service
Technology
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency
Service
Technology
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency
Service
Technology
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency
Service
Technology
Workflow/Logistics
Organization/Infrastructure
Personnel/Training/Competency

8 Key Change Concepts
• Engaged leadership;
• Quality improvement strategy;
• Empanelment (linking each patient with a
responsible primary care provider);
• Continuous and team-based healing
relationships;
• Organized, evidence-based care;
• Patient-centered interactions;
• Enhanced access; and
• Care coordination.
Wagner , Ed et al.
Guiding Transformation: How Medical Practices
Can Become Patient-Centered Medical Homes
www.commonwealthfund.org; February 2012

National Academy of State Health Policy
Consortia to Advance Medical Homes for Medicaid & CHIP Participants
1. Strategically engage partners.
2. Set performance expectations and implement a process to
identify practices that meet expectations.
3. Compensate & motivate practices through enhanced payment.
4. Help practices meet expectations & improve performance.
5. Evaluate program performance.
Commonwealth Fund Building Medical Homes: Lessons from Eight States with
Emerging Programs (Dec. 2011)

National Academy of State Health Policy
Common Themes
1. Tailor PCMH definition to reflect state needs, priorities & circumstances.
2. Use payment policy to foster collaboration among primary care and specialty
care.
3. Use payment policy to reward more capable and better-performing medical
homes.
4. Help practices improve performance.
5. Provide support for care coordination.
6. Ease the evaluation burden for medical home providers.
7. Base medical home qualification criteria on models established by a national
organization.
8. Balance the desire for improved performance with the cost of the
improvements.
9. Address antitrust concerns that arise when multiple payers create a medical
home program.

ACP Medical Home Builder®
www.medicalhomebuilder.org

Three Categories of Modules
(Current as of 4/26/12)
• Quick Start: NCQA*
• Organize Your Practice
• Work as a Team
• Communicate with Patients
• Enhance Patient Access
• Deliver Patient-Centered Care
• Coordinate Care
• Facilitate Transitions I & II*
• Use of Technology I & II
*Modules (11) added since launch in August 2011
White = PCMH: Green = Clinical; Yellow = Practice Mgt
• Improve Quality
• Manage Populations
• Manage Patients’ Medications*
• Engage Patients*
• Manage Diabetes Mellitus*
• Immunize Adults*
• Depression Screening & Care*
• Manage Chronic Pain*
• Practice Basics*
• Managing People*
• Bloodborne Pathogens/OSHA*
• Manage Medical Waste*

Planned Enhancements
Improving Clinical Care
• Arthritis
• Cardiovascular Risk Factors
• Choosing Wisely (High
Value, Cost-Conscious
Care)
• Additional Clinically-
Related modules to follow
Green = Clinical; Yellow = Practice Mgt
Managing Your Practice (For
example only; actual topics
to be determined)
• Financial Management
• Coding
• Billing/Collections
• Working on aligning MHB
modules with
Maintenance of
Certification requirements
• New data download
capability for users

New Module Landing Page Design

Module Organization

Practice Biopsy Questions

Biopsy Report
• Highlights
critical issues
• Percentage
score
• Guidance
based on
responses
• Links to key
resources &
Resource
Library

Module Resource Library

Virtual Bookshelf / Resource Library

Practice-to-Practice Connections

Reporting Features
• Premium license
permits data
aggregation at level
of practice location,
practice group, or
groups of practices
• Drill down capability
to individual
• Provides average
score from entire
MHB community for
benchmarking
• Indicates # of
individuals who have
completed particular
module in
community
• Additional reports on
a customized basis

Current Groups Using MHB
• CareFirst BlueCross BlueShield (MD/VA/DC)
• Independence Blue Cross (PA)
• Connecticut State Medical Society IPA (CT)
• Eastern Connecticut PHO (CT)
• Mercy Medical Associates (Maine)
• St. Francis Health System (OK)
• Temple University General IM (PA)
• University Medicine (RI)
• West Penn Allegheny Health System (PA)
• Monroe Plan for Medical Care (NY)
• University of Texas Health Science Center (TX)
• Southern Illinois University (IL)
• Louisiana Health Care Quality Forum (LA)
Groups (exclusive of 2,000
practices from CareFirst
BCBS) currently represent:
• >1000 clinicians
• >300 locations
CareFirst:
• 2,000 practice licenses
• Approx. 6,000 clinicians

Map of Current Users (7/31/12)

My patients are those who
come to see me
Chief complaint determines
care
Care is determined by today’s
problem and time available
Care varies by time, memory,
and skill of doctor
Patients coordinate their own
care
Personal confidence based on
training
Acute care is delivered by next
available appt and walk-in
Patient relates interval history
Operations are doctorcentered
Adapted from Malcolm Cox and Richard Stark
U.S. Department of Veterans Affairs
My patients are those who are
part of our medical home
Systematic assessment of
patient needs
Care is determined by
proactive plan
Standardized care based on
EBG and CDSS
Prepared team of professionals
coordinates care with patient
Outcomes are assessed;
continuous improvement
Acute care is delivered by
advanced access/non-visit care
Tracking of tests/procedures &
consultations/hospitalizations
Multi-disciplinary team works
at “top of license” for patients

What Does a PCMH + Neighbor Look Like
From a Patient’s Perspective?
Access/Communication
Between Face-to-face Encounters visit
•Contact via traditional/health IT-enabled
•Planned/prepared
•Online vs. phone
processes
•Coordinated •Open access activities/co-management
vs. delayed visits
•Collaboration with other health care providers
•Team-based •Email effort vs. with snail staff mail & colleagues
•Transparent information sharing
•Use •PHR of customized and practice educational portal 24/7/365 materials
•Interactive PHR with lab/test results, etc.
•Clinicians •Information knowledgeable prescription
about specialty care
•Remote monitoring

Defining Success
“Success is falling nine times
and getting up ten.”
-- Jon Bon Jovi

Defining Success
Indicator If FLORIDA improved its performance to the level of the bestperforming
state for this indicator, then:
Insured Adults 2,048,106 more adults (18-64) would be covered
Insured Children 601,618 more children (0-17) would be covered
Adult Preventive Care 652,393 more adults (50+) would receive recommended care
Diabetes Care 265,081 more adults (18+) would receive eye exam, foot exam, HbA1c
Childhood Vaccination 35,898 more children (19-35 months) would be UTD
Adults with USOC* 1,750,697 (18+) would have usual source of care
Children with MH** 502,788 (0-17) would have medical home
Preventable Admissions 37,917 fewer hospitalizations for ASC*** among Medicare beneficiaries
$145,566,318 dollars would be saved
Hospital Re-admits 7,660 fewer re-admits; $59,254,092 would be saved
Amenable Mortality 3,307 fewer premature deaths (before age 75)
http://www.commonwealthfund.org/Maps-and-Data/State-Data-Center/State-Scorecard/DataByState/State.aspx?state=FL
*USOC = usual source of care; **MH = medical home;
***ASC=ambulatory care sensitive conditions

"I put a dollar in a
change machine.
Nothing changed."
— George Carlin

“You must be the change you
want to see in the world.”
-Mahatma Gandhi

Michael S. Barr, MD, MBA, FACP
Senior Vice President
Medical Practice, Professionalism & Quality
mbarr@acponline.org
202-261-4531