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Population Health News

Incremental Effort Can Craft the Patient-Centered Medical Home

By Jennifer Bresnick

- Achieving patient-centered medical home recognition takes time, resources, guidance, and a dedication to holistic practice transformation, but the process doesn’t necessarily have to be a single, big-bang effort. While certain criteria must be met in order to snag the coveted designation from the NCQA or other accrediting bodies, healthcare providers are allowed to work towards their population health management and care coordination goals at their own pace before signing up for an assessment.

In this installment of’s practice transformation series, Pam Minichiello, Project Director at the Massachusetts eHealth Collaborative (MAeHC), details her experiences with leading healthcare providers towards their patient-centered medical home recognition and explains how small changes can bring big results for organizations that invest in more coordinated, patient-centered care.

“I think that anybody can do it,” Minichiello says.  “Is it easier for some organizations rather than others?  Yes, absolutely.  But it really is dependent upon their commitment to the process and what their drivers are. It does take resources.  But it also drives efficiency within the practice.  It increases patient satisfaction, overall performance, as well as population health management.  It’s so important to use these models to meet the challenges that are going on right now in healthcare.”

MAeHC has been helping to bring EHR adoption, health information exchange, and other health IT expertise to Northeastern communities for more than a decade, focusing on driving interoperability, clinical analytics, population health management, and care coordination throughout New York and New England.  Minichiello has been doing her part with MAeHC since 2008 by consulting with and educating organizations angling to implement NCQA PCMH protocols.

This includes working with organizations in the region’s many rural areas, where vast distances and long winters can isolate communities and make it more difficult to connect patients with the services they need.  “A rural area may not have expanded care management services near them for patients, or their patients are very remote,” she explained.  “We do a lot of work up in the northern Adirondack Region of New York State, for example, and that area is quite geographically sparse.  Especially during the winter, patients are difficult to get a hold of and manage.”

READ MORE: NCQA Revamps Patient-Centered Medical Home to Ease Adoption

“But sometimes in those more rural areas, the groundwork for patient-centered care is already in place.  They’re used to having that personal relationship.  Some of these patients have had the same doctor since birth.  And the physicians definitely feel a high degree of allegiance to their patient population.”

A strong understanding of the patient population and its needs is an important first step towards implementing the patient-centered medical home.  And starting this spring, so is EHR adoption.

“Beginning at the end of March, the NCQA standard will be upgraded to what they are calling the 2014 standard, which pretty much requires an EHR,” Minichiello says.  “Under the 2011 standards and the earlier standards in 2008, a paper-based practice could receive some level of recognition, but they couldn’t go higher than Level 2.  But without an EHR, you can’t generate the necessary reports, and it’s very difficult to identify and manage populations.”

“Starting now, providers will have to be on an EHR in order to receive any recognition, or they have slim to none chance of getting there under the new rules,” she added.  “Everything is related to care coordination and closing that loop: identifying, and managing, and tracking those populations, managing quality and clinical performance.  So you want to make sure that you have reporting capabilities.  You want to make sure that you have an EHR that supports that.”

Adopting and optimizing an EHR is a difficult task, but it will provide an important foundation for addressing the six fundamental PCMH tasks that can lead to recognition: expanding care access, using data for population health management, managing the care of individual patients, supporting the self-care process, tracking referrals and follow-ups, and striving for continuous quality improvement.

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“We’ve been working with Valley Health Partners in Western Massachusetts for the past four years,” Minichiello said.  “They were involved in a payer incentive program where they were required to do things that were what we like to call ‘medical hominess,’ where they would adopt certain workflows and certain standards of the NCQA patient-centered medical home requirements, but not the whole package.”

“So for the first three years that we worked with them, they would pick a couple of the standards and they would develop and implement those workflows and those processes,” she continued.  “Then the next year, they would pick two more, and so on.  But in 2014 they decided to go for full recognition, and it was easier for them because they had already adopted a lot of the ‘must-pass’ elements.  So they weren’t starting from square one.”

practicetransformMoving incrementally towards meeting the PCMH criteria might not be feasible for everyone, but it can be effective for practices that need to utilize their resources carefully or may lack the financial and administrative wherewithal to implement all aspects of the PCMH at once.  “Having available clinical staff is sometimes difficult in some smaller practice,” says Minichiello.

“There are still practices out there where there is one provider and one non-clinical staff person.  The administrative person may put the patient in the room, but they also are scheduling the appointments and answering the phone. You want to make sure that you have some kind of clinical staff member, either within the practice or through an affiliated organization, who can provide care management and patient education.”

However, having the staff members available doesn’t always guarantee a smooth ride, especially for the consultants brought in to shake up the way patients are managed and workflows are executed.  “A lot of times, we’re brought in to be the bad parent, because there can be a lot of pushback and staff members aren’t always willing to make the changes right away,” Minichiello says.

READ MORE: NCQA: Patient-Centered Medical Home No Longer “Unduly Onerous”

“I’m working with one organization on the tracking of referrals, and I had literally a clerical staff member hang up on me.  She said, ‘This is stupid.  I don’t want to do it,’ and she hung up.  So I called her back and said, ‘All right.  Let’s talk about it, and let’s understand why we’re doing this and what the issues are.’”

In cases where unwilling participants make it difficult to accomplish necessary tasks, going slowly and allowing some give-and-take with skeptical team members may be the only way to enact meaningful change.  “I’d like to say that most of the time, we try our best to make it work for the provider,” says Minichiello.  “We don’t try to take you and mold you into a specific model.  We try to take your current workflows and optimize those workflows to meet the model.  And we also provide education as to why these things are important and why we’re doing them.  It’s not just to check off a box.”

“In the end, I think that the majority of providers do see a benefit to the implementation and the practice transformation, but you will always have those naysayers.  They’re everywhere, and you have to work around that.”

For organizations that are ready and willing to put in the work, creating a team of clinical and non-clinical staff dedicated to PCMH transformation will help to ensure that all aspects of patient care coordination can be appropriately divided and conquered.  The ability to follow up with patients when they are outside of the office setting is one of the key features of the patient-centered medical home, and that requires more than just the technology to send continuity of care documents (CCDs) or admission, transfer, and discharge (ADT) alerts between the primary care setting and the local hospital.

“One of the best things to do is to have a pharmacist on your patient-centered medical home team to manage those patients that have poly-pharma,” Minichiello suggests.  “It’s a huge benefit to integrate pharmacy services and have a pharmacist follow-up with a patient after an inpatient discharge and do medication reconciliation with that patient or their caregiver.  I can’t tell you how many times the pharmacist has found mistakes that wouldn’t have been caught otherwise.”

“Sometimes people will go to the doctor and sort of just bob their head when they’re asked questions about their medications, and they don’t really get how important it is,” she added.  “Sometimes they don’t even know what their medications are.  They just take them.  So educating those patients and getting them more involved becomes a huge plus.”

Understanding the needs of patients once they leave the hospital and return to their communities is also a critical aspect of the PCMH.  Studies have shown that hospitalizations can impact a patient’s ability to make decisions for themselves, especially among the elderly.  “Care coordination is one of the things that helps decrease those preventable hospital readmission rates, because when patients are discharged, they’re given all these instructions that go right over their heads,” Minichiello explains.

Family caregivers are extremely important for a smooth transition between care settings, but not all patients have the social support structure they need to readjust to their life at home.  In those cases, providers must be equipped to fill the gap.  “If the patient doesn’t have someone looking out for them, they might go home and find out they don’t have a walker, or they didn’t have an elevated toilet seat, so they went home and fell down and they land right back in the hospital,” she says.  “That kind of thing can be prevented with a little extra care.”

Bolstering a provider’s care coordination efforts does not require full commitment to the patient-centered medical home model – or even the use of an electronic health record or population health management tool – yet still produces a tangible impact on the quality patient care, moving the organization one step closer to being able to check off a “must-pass” or two if they decide to continue their efforts.

Whether a provider intends to fully commit to achieving patient-centered medical home recognition all at once or opts for a more staggered approach, the first place to start is with some basic education, Minichiello says.  “Just to get some education about the baseline requirements,” she says.  “You don’t have to understand them verbatim, but it helps to know what the role of the provider is going to be, and what the patient is going to be responsible for.  Just start to think about those things.”

“Secondly, look around at your staff and see what your staff is currently doing and start to prepare them for embracing some kind of change,” she continues.  “Nobody likes to change what they do every day.  People like what they like.”

“But you can start to look around and say, ‘You know, I have Mary over here and she’s a nurse, and she’s not really working up to her fullest capacity.  Where could I better use her skills in my practice?  Do I have affiliated services around me I could use? What populations do I want to manage?  What technologies do I need to make that happen?’ Assessing your needs and goals and the resources you already have is a great way to understand how far you have to go and what it will mean for your organization.”


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