Project ID: 2.a.ii
Project Name:
Patient Centered Medical Homes (PCMH)
Project Description:
Increase certification of primary care practitioners with PCMH certification and/or Advanced Primary Care Models (as developed under the NYS Health Innovation Plan (SHIP))
Project Chairs:
David Haswell, MD, Bassett Medical Center
Martha Sunkenberg, Bassett Medical Center
Objective:
To transform all safety net providers in primary care practices into NCQA 2014 Level Three Patient Centered Medical Homes (PCMHs) or Advanced Primary Care Models.
Rationale and Relationship to Other Projects:
A key component of the health care transformation is the provision of high quality primary care for all Medicaid recipients, and uninsured, including children and high needs patients. The PCMH and Advanced Primary Care models are transformative, with strong focus on evidence based practice, population management, coordination of care, HIT integration, and practice efficiency. Such practices will be imperative as the health care system transforms to a focus on community based services. This project will address those providers who were not otherwise eligible for support in this practice advancement as well as those programs with multiple sites that wish to undergo a rapid transformation. Performing provider systems undertaking this project, while focused on the full range of attributed Medicaid recipients and uninsured, should place special focus on ensuring children and their parenting adults, and other high needs populations have access to the high quality of care inherent in this model, including integration of primary, specialty, behavioral and social care services. The end result of this project must be that all primary care providers within the performing provider system must meet NCQA 2014 Level Three PCMH accreditation and/or meet state-determined criteria for Advanced Primary Care Models by the end of DSRIP Year 3, and successfully sustain that practice model with improvement in monitored quality improvement metrics through the end of DSRIP.
Core Components:
Provider organizations who wish to include this project should review the extensive literature available from such resources as TransforMed. Practices will be expected to meet NCQA 2014 Level 3 Medical Home standards or NYS Advanced Primary Care Model standards by the end of DSRIP Year 3 (Technology Innovation Plan Initiative). They must also effectively sustain the model and show continuous improvement in monitored practice metrics.
The following components must be included in this project:
- Identification of a physician champion with knowledge of PCMH implementation who can assist with meeting all components of the NCQA requirements including skills of population management through EHR and process improvement methods.
- Gap analysis of practice sites within the PPS system.
- Identification of care coordinators at each primary care site who are responsible for care connectivity and engagement of other staff in PCMH process as well connectivity to other care managers who provide care coordination for higher risk patients (e.g., health home care managers).
- Implementation of necessary HIT functionality including EHRs that meets meaningful use standards (MU), HIE connectivity, e-prescribing, instant messaging, ER alerts; active participation in local RHIOs/SHIN-NY will also be required by all eligible participating providers in the Performing Provider System.
- Staff training on care model including evidence based preventive and chronic disease management.
- Preventive care screenings including behavioral health screenings (PHQ-9, SBIRT) will be implemented for all patients to identify unmet needs. A process must be developed for assuring referral to appropriate care, if not provided in the practice, in a timely manner, including a “warm hand-off” where possible.
- Implementation of open access scheduling.
- Development of quality management program to monitor process and outcome metrics and to implement improvement strategies including rapid cycle improvements to ensure fidelity with PCMH standards and practice quality improvement. The program should include reporting to staff and patients.
- Monitoring of financial status.
- Demonstration of a clear cultural competence and willingness to engage Medicaid members in the design and implementation of system transformation, including addressing issues of health disparities.