The Patient-Centered Medical Home

Edition: September 2013 - Vol 21 Number 09
Article#: 4323
Author: Repertoire

Editor’s note: This is Part 1 of a two-part series on the patient-centered medical home. This month, Repertoire looks at the concept, the types of practices that are getting involved, and the role of mid-level providers in them. Next month, we’ll take a look at the role that specialists and electronic medical records are playing in the medical home/neighborhood, and how sales reps should approach these new practices.

As physicians shift from an episodic model of delivery to coordinated care, sales reps may have to change their approach as well

Change is coming to the nation’s primary care doctors, and specialists too. Some believe it’s the future of medicine. Others believe it’s what medicine always should have been, but for a dysfunctional fee-for-service reimbursement system.

The change is called the “patient-centered medical home,” and observant sales reps will be able to detect it among their customers, according to those with whom Repertoire spoke. No, you won’t find any flags outside physician practices’ doors signifying they are a patient-centered medical home, points out Andy Rice, Henry Schein U.S. medical training manager. But the concept is gaining significant traction across the entire spectrum, he adds. So be prepared.

“[Sales reps] won’t be going into medical practices that operate like mom-and-pop shops anymore,” says Bruce Bagley, MD, FAAFP, interim president and CEO of TransforMED, a subsidiary of the American Academy of Family Physicians. That doesn’t mean the patient-centered medical home has to be a big practice. But it will be more sophisticated than others. “Typically, practices that haven’t undergone any transformation lack a professional approach to the management of their finances, people and clinical quality – though that doesn’t mean they don’t take good care of their patients,” he says. “But [when sales reps] go into practices that have been recognized [as patient-centered homes], they’re going into a more sophisticated organization, in terms of leadership, decision-making and IT support.”

Selling to such practices will call for different skills, continues Bagley. No longer can reps sell diagnostic tests and equipment – traditional revenue-generators for most practices – on an ROI basis. “The new conversation is, ‘What can [the device’s] contribution be to the overall efficiency and effectiveness of the organization?’” he says. “Think of the accountable care organization. It has many different components – primary care, specialty care, IT – and each one of those components has to demonstrate its contribution to the effectiveness and efficiency of the enterprise.” In such a setting, the physician’s office might be viewed as a cost center, whose challenge is to keep costs under control while getting superior results in terms of patient care. “It’s a very different mindset,” says Bagley.

Coordinated – not episodic – care

The American Association of Family Practitioners says the patient-centered medical home “is a transition away from a model of symptom- and illness-based episodic care to a system of comprehensive coordinated primary care for children, youth and adults. Patient centeredness refers to an ongoing, active partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive and chronic care management through all stages of life. These personal physicians are responsible for the patient’s coordination of care across all health care systems facilitated by registries, information technology, health information exchanges, and other means to ensure patients receive care when and where they need it.

“With a commitment to continuous quality improvement, care teams utilize evidence-based medicine and clinical decision support tools that guide decision-making as well as ensure that patients and their families have the education and support to actively participate in their own care. Payment appropriately recognizes and incorporates the value of the care teams, non-direct patient care, and quality improvement provided in a patient-centered medical home.”

Since it was first introduced, the concept of the patient-centered medical home has evolved, according to experts. “It remains a solid construct about improving the patient-clinician relationship and the practice infrastructure to coordinate across the variety of needs a patient may have,” says Tricia Barrett, vice president of product development, National Committee for Quality Assurance, which, as of July 2013, had formally recognized 5,770 patient-centered medical homes. “I would say that there has been a shift toward proactive, population health management – away from episodic, illness-based care – and towards team-based support, [away] from doctor knows best.

“Our standards have morphed, certainly, since the original release in 2008,” she adds. “As practice capabilities have evolved and knowledge of the relative value of various components of the model has emerged, we have modified the program standards and scoring to emphasize those that are critical functions and those that have value in differentiating among practices. This is reflected in the changes to our ‘must pass elements,’ alignment with ‘meaningful use’ [of electronic medical records systems], and increased focus on the integration of behavioral health support, among other things.”

More focused approach

Says Bagley, “If anything, [the concept of the patient-centered medical home] may have become more focused on a few critical areas. Initially, anyone could talk about anything they wanted; it was a concept that everybody could rally around. Since then, some of the more effective strategies have come into focus.” Those strategies include the following:

Team-based care. In the patient-centered home, no longer is the physician considered the source of all knowledge, wisdom and decision-making. “In the past, we bundled [patients] from the front to the back of the office, put them in the exam room, and when the doctor walked in the door, the magic started,” says Bagley. “That’s no longer OK. There’s so much more the team can do, such as patient education, patient self-management and between-visit follow-up. So it’s not just about doctoring, but about care. And it’s not the old concept of the multidisciplinary team, that is, a bunch of professionals who work on the same patient but don’t talk to each other. Now you talk about how to get the best results.”

Patient self-management. “We used to talk about ‘non-compliant patients,’” says Bagley. “Now we need to take responsibility for helping our patients have a role in caring for themselves. We talk about patient activation scores [to gauge a patient’s knowledge, skills and confidence to care for himself or herself], motivational interviewing, follow-up visits, home monitoring and patient coaching.”

Risk-stratified care management/care coordination. When Bagley talks about “risk,” he is referring to the risk that a patient can’t manage his or her way around the healthcare system, perhaps because of frailty, multiple chronic illnesses, or some other reason. “We need to figure out how to help them get the help they need,” he says. Today’s electronic medical records systems can help. “You need a point-of-care registry,” that is, a system that allows whomever is with the patient – regardless of physical location – to see the patient’s current status, gaps in care, care plan, caregivers, etc.

“While the concept has not changed significantly for those who understand the depth of what is intended, the use of the term ‘patient-centered medical home’ itself may have lost some of its profoundness by those who don’t really understand the significance of the terminology,” says Allyson Gottsman, executive vice president, HealthTeamWorks, Lakewood, Colo., a 501(c)3 non-profit collaborative working to redesign the healthcare delivery system and promoted integrated communities of care.

“A particular example are the primary care physicians who are practicing in the traditional model but who say ‘I have been a medical home for years,’” she says. “When you ask someone if they give patient-centered care, everyone thinks that is what they have already been doing. There has been a real need for a ‘road map’ for doctors to follow so that they have specific steps to implement all of the [patient-centered-medical-home] components.”

Any and all sized-practices

Any practice – big or small – can be a patient-centered medical home, according to those with whom Repertoire spoke.

“Whether a practice is large or small, urban or rural, if they have the right resources, they can implement systems to provide population management, care coordination, better access, and evidence-based care,” says Gottsman. “Continuous quality improvement can and should be provided in any primary care setting.” That said, she believes it is critical that practices aspiring to patient-centered-medical-home status make use of practice coaching to provide the accountability and guidance necessary for the redesign.

“Practices that have leadership, [and that are] knowledgeable and committed to medical home principles, are ideal,” says Peggy Reineking, director of clinical recognition programs, NCQA. “This requires a mental transformation on the part of the whole staff, so leadership is essential. This can occur at a practice of any size, including solo practices and practices with 80 sites.”

Adds Barrett, “I don’t believe there is a single ‘sweet spot’ for [the patient-centered medical home]. Our experience has shown us that practices of all types and sizes are capable of delivering this model and find a variety of benefits to doing so. It is true that the practice has to embrace the model as a team and that some individuals may not be willing to change their thinking and their approach to align with the new model. But that is about the individual – not the model or the size/type of practice.”

IDNs in the picture

What happens if a practice that operates as a patient-centered medical home is acquired by a hospital system? “I’m not sure I can answer this one,” says Barrett. “It probably depends on the mindset of the hospital system and the reasons for the acquisition. They might bring a stronger supportive infrastructure and capital investment to provide better tools to deliver the [patient-centered medical home] model, or they might be simply looking for more sources of referrals, which could put the practice and the owner hospital at odds.”

Says Gottsman, “The literature suggests that hospital systems in general have not fully empowered acquired primary care practices to operate to the same extent as independent practices. One important consideration is that when you become a successful [patient-centered medical home], you are often very effective at reducing what amounts to the hospital’s top line revenue – emergency department visits and inpatient bed days. While we have seen enlightened hospital CEOs who are focused on moving to a delivery system that will thrive in a value-based compensation model, and excellent examples of robust support of PCMH by hospital systems, at the moment there is not a widespread acceptance by hospital CEOs.

Not just the doctor

Empowered support teams are a surefire mark of the patient-centered medical home, according to experts.

“We have seen considerable variability in how practices take advantage of the skills, training, and education of mid-level providers,” says Gottsman. “I think it’s fair to say that in all cases, regardless of how they are utilized, mid-level providers have become an integral part of the patient-centered medical home.

“Some practices have chosen to use mid-level clinicians as complex case managers, working to support the complex patients and their families as they transition through various care settings,” she says. “We also see mid-levels helping to manage the complex comorbidities, empowering caregivers to manage the health of the patient.”

Some practices use mid-levels to enhance access and make same-day appointments available for acute care, thus enabling physicians to be available to manage their panel of patients and provide better continuity of care, continues Gottsman. In another model, the mid-level clinician has a panel of patients whose health he or she manages. “This tends to be a smaller panel, but often includes some of the more challenging patients. In this model, the mid-level, working closely with the physician, is able to spend more time with each patient.

“When there is compensation for improved quality and lower costs, having less expensive mid-levels spend more time with complex patients is a good economic strategy.”

“The [patient-centered medical home] model encourages everyone in the practice to act at the top of their capabilities/license,” says Barrett. “I think the model empowers all individuals in the practice, and that includes mid-level providers. It is so much more motivating to be able to use your full range of skills; and by doing so it helps even out the work load for everyone.” Sales reps may notice a well-organized practice with defined roles and responsibilities for all team members, she says. “This might include others having more of a role in purchasing products, supplies and equipment. They will, hopefully, have a stronger patient voice in their practice and that might change how they think about some supplies.” Dressing gowns, for example.


Coordinating care can pay off

Roughly 500 primary care practices have signed up to participate in the Comprehensive Primary Care Initiative, a program of the Centers for Medicare & Medicaid Services’ Innovation Center. Modeled after practices developed by large employers and others in the private sector, the initiative works with commercial and state health insurance plans to financially reward practices for delivering higher-quality, better coordinated, and more patient-centered care. The goals of the program parallel those of patient-centered medical homes.

These financial resources are designed to help doctors work with patients to ensure they:

• Manage care for patients with high healthcare needs. Participating primary care practices will deliver intensive care management for patients with high needs. By engaging patients, primary care providers can create a plan of care that fits each patient’s individual circumstances and values.

• Ensure access to care. Because healthcare needs and emergencies are not restricted to office operating hours, primary care practices must be accessible to patients 24/7 and be able to use patient data tools to give real-time, personal healthcare information to patients in need.

• Deliver preventive care. Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.

• Engage patients and caregivers. Primary care practices will have the ability to engage patients and their families in active participation in their care.

• Coordinate care across the medical neighborhood. Under this initiative, primary care doctors and nurses will work together and with a patient’s other healthcare providers and the patient to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.

Editor’s note: Is one of your customers participating in the Comprehensive Primary Care Initiative? Find out at this URL:

Sidebar 2:

Standards to meet

The patient-centered medical home is a model of care that emphasizes care coordination and communication to transform primary care into “what patients want it to be,” according to the National Committee for Quality Assurance. Patients in medical homes receive culturally and linguistically appropriate care, when and where they need it. Research confirms that medical homes can lead to higher quality and lower costs, and can improve patient and provider experiences of care.

NCQA reports that its Patient-Centered Medical Home (PCMH) recognition is the most widely adopted model for transforming primary care practices into medical homes. More than 27,000 clinicians at 5,700 practice sites earned PCMH recognition in the first four and a half years of NCQA’s program.

NCQA PCMH recognition is based on six standards:

• Enhance access and continuity. Accommodate patients’ needs during and after hours, provide medical home information, offer team-based care.

• Identify and manage patient populations. Collect and use data for population management.

• Plan and manage care. Use evidence-based guidelines for preventive, acute and chronic care management.

• Provide self-care support and community resources. Give patients and families information, tools, resources.

• Track and coordinate care. Track and coordinate tests, referrals, care transitions.

• Measure and improve performance. Use performance and experience data for continuous improvement.

PCMH standards give practices the freedom to decide the best way to become medical homes, based on their size and other factors. Three levels of recognition are available, and the standards’ adaptability helps diverse practices succeed, regardless of their configuration, electronic capabilities or location.

The standards also incorporate federal “meaningful use” definitions. Clinicians at practices that meet the highest NCQA requirements are positioned to qualify for meaningful use bonuses.

Source: “NCQA Patient-Centered Medical Home: Health care that revolves around you,” by the National Committee for Quality Assurance.


Who’s looking at patient-centered homes?

The National Committee for Quality Assurance ( has recognized more than 5,700 physician practices as patient-centered medical homes since 2008. (See related article.) But physician practices can seek validation of their status as patient-centered medical homes by several other organizations as well.

The Joint Commission

Launched in July 2011, Primary Care Medical Home (PCMH) Certification for Joint Commission-accredited ambulatory care organizations focuses on care coordination, access to care, and how effectively a primary care clinician and interdisciplinary team work in partnership with the patient (and where applicable, their family). As of July 22, 2013, The Joint Commission had recognized 70 organizations with PCMH certification, representing more than 700 sites of care and more than 2 million patients.

The PCMH certification option also focuses on education and self-management by the patient, according to the organization. Patients benefit from this model of care because they have increased access to their primary care clinician and interdisciplinary team; their care is tracked and coordinated; and increased use of health information technology supports their care.

The Joint Commission’s PCMH certification option is based on the Agency for Healthcare Research and Quality’s definition of a medical home, which includes these core functions

and attributes:

Patient-centered care. Relationship-based care focuses on the whole person and understanding and respecting each patient’s needs, culture, values and preferences.

Comprehensive care. A team of providers (may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, mental health workers, social workers and others) work to meet each patient’s physical and mental health care needs, including prevention and wellness, acute care and chronic care.

Coordinated care. Care is coordinated across the broader health care system, including specialty care, hospitals, home care and community services and support. This is particularly critical during transitions between sites of care, such as when patients are discharged from the hospital.

Superb access to care. Patients have access to services with shorter waiting times for urgent needs, enhanced in-person hours, around the clock telephone or electronic access to members of the care team, and alternative methods of communication such as e-mail and telephone.

Systems-based approach to quality and safety. The PCMH uses evidence-based medicine and clinical decision support tools, engages in performance measurement and improvement, measures and responds to patient experiences and satisfaction, practices population health management, and publicly shares robust quality and safety data and improvement activities.

Organizations interested in pursuing the PCMH certification option must comply with both the existing Joint Commission ambulatory care requirements and additional PCMH-specific requirements. The PCMH requirements are incorporated into the ambulatory care on-site accreditation survey. Just like accreditation, the PCMH certification option applies to the entire organization, covers a three-year period, and is posted on the Quality Check portion of The Joint Commission’s website.

In February 2013, The Joint Commission announced a PCMH certification option for hospitals and critical access hospitals with ambulatory care services that include the provision of primary care services offered by a primary care clinician. Surveys for this add-on certification option can be conducted in coordination with the regular on-site accreditation survey or separately.

In May 2013, The Joint Commission announced it would begin offering a Behavioral Health Home Certification option in January 2014. Behavioral health homes integrate physical healthcare services with behavioral healthcare to provide treatment that addresses the needs of the whole person, according to The Joint Commission. Behavioral health home providers do not need to provide all the services themselves, but must ensure that the full array of primary and behavioral health care services is available and coordinated.

Accreditation Association for Ambulatory Health Care Inc.

AAAHC began recognizing medical homes in 2009, and to date, has formally recognized 226 Medical Homes and 31 Dental Homes. AAAHC offers two options for organizations to achieve recognition as a Medical Home: certification and accreditation.

Medical Home On-site Certification evaluates a practice against AAAHC Standards for a Medical Home. As with the accreditation program, AAAHC surveyors make an on-site visit to assess, at the point of care and from a patient perspective, how the organization meets these Standards, which focus on:

1) patient rights and responsibilities;

2) organizational governance and administration;

3) the patient/care team relationship;

4) comprehensiveness, continuity and accessibility of care;

5) clinical records and health information; and

6) quality of care.

Medical Home Accreditation is AAAHC’s highest achievement for primary care, centering on a comprehensive review of the entire ambulatory care organization. The peer-based process is conducted by professionals who are experienced ambulatory healthcare providers. During the on-site survey, surveyors work with the practice to assure that its patients receive high-quality care consistent with AAAHC Standards for the ideal Medical Home model.

Source: Accreditation Association for Ambulatory Health Care Inc.,


URAC has 30 accreditation programs spanning the health care spectrum. Most recently, the organization was approved by the Department of Health and Human Services to accredit health plans on health insurance exchanges being implemented in 2014 in all 50 states and the District of Columbia.

Practices receiving the URAC Medical Home Achievement seal offer a higher standard of service and quality to their patients, increased access to services and better care coordination; and they ensure active patient engagement in all care decisions and compliance. The program also aligns with the “Joint Principles of the Patient Centered Medical Home,” issued jointly by the four leading national primary care medical societies.

The better care and quality offered by medical homes make them eligible for special reimbursement incentive programs offered by the federal and a number of state governments, as well as a large number of private insurers, according to URAC. Such practices also attract patients to their doors with their heightened level of quality and customer-friendly service.

To qualify for URAC’s Medical Home Achievement seal, a practice must be reviewed onsite by a URAC Certified Auditor or a URAC Clinical Reviewer. A one- or two-day onsite review will occur, dependent on the size of the practice. Upon successful completion, URAC Medical Home Achievement is awarded for a two-year time frame. (Note: URAC offers practices two levels of recognition: Achievement, and Achievement with electronic health records.)

URAC’s Medical Home Achievement focuses on seven modules essential to effective primary healthcare:

• Core quality care management.

• Patient-centered operations management.

• Access and communications.

• Testing and referrals.

• Care management and coordination.

• Advanced electronic capabilities.

• Quality performance reporting and improvement.

For more information about URAC’s Medical Home Achievement, contact Seth Brenner at or (202) 326-3973.