Defining & Recognizing a Medical Home

Definition: According to Iowa’s 2008 Health Care Reform Act (House File 2539), a patient-centered medical home means an, “approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access all medical and nonmedical health-related services needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in section 135.158.” Section 135.158 identifies the following characteristics:

• Personal provider
• Provider-directed medical practice
• Whole person orientation
• Coordination and integration of care
• Quality and safety
• Enhanced access to health care
• Appropriate payment.

• Development of continuity of care documents to aid in communication across care settings
• Development of personal treatment plans
• Comprehensive patient evaluations
• 24-hour provider accessibility
• Use of a protocol or standards for tracking patient referrals
• Provision of same-day services when appropriate
• Designation of a dedicated care coordinator
• Establishment of a disease management program (practices must focus on diabetic patients in year one)
• Establishment of a wellness/disease prevention program
• Use of health information technology
• Use of a system to remind patients about preventive services
• Establishment of a system to share information with the University of Iowa Health Center for specialty care

• End of Year 1: 20% of practices must be NCQA Level 1 recognized or JC accredited;
• End of Year 2: 30% of practices must be NCQA Level 1 recognized or JC accredited, and 10% of practices must be NCQA Level 2 recognized or JC accredited;
• End of Year 3: 10% of practices must be NCQA Level 1 recognized or JC accredited; 40% of practices must be NCQA Level 2 recognized or JC accredited, and 10% of practices must be Level 3 recognized or JC accredited.
• Subsequent Contracts: 80% of practices must receive NCQA recognition or JC accreditation.

Definition: The Massachusetts Patient-Centered Medical Home Initiative (PCMHI) has identified 12 core competencies for participating practices:

1. Patient/family-centeredness
2. Multi-disciplinary team-based approach to care
3. Planned visits and follow-up care
4. Population-based tracking and analysis with patient-specific reminders
5. Care coordination across settings, including referral and transition management:
6. Integrated care management focused on high-risk patients
7. Patient and family education
8. Self-management support by all members of the practice team
9. Involvement of the patient in goal setting, action planning, problem solving and follow-up
10. Evidence-based care delivery, including stepped care protocols
11. Integration of quality improvement strategies and techniques:
12. Enhanced access

Recognition: PCMHI practices are required to achieve at least National Committee for Quality Assurance (NCQA) Level 1 recognition. In addition, practices are expected to achieve three otherwise optional NCQA standards. Participating practices must achieve NCQA Level 1 “plus” recognition within 18 months of project launch.

Practices that are designated under the BCBSM Physician Group Incentive Program (PGIP) must meet guidelines within twelve “domains of function.” The specific domains are: patient-provider partnerships; patient registries; performance reporting; individual care management; extended access; test results tracking & follow-up; preventive services; linkages to community services; self-management support; patient web portals; coordination of care; and specialist referral processes.

• Perform primary care that include certain preventative services;
• The ability to create and maintain a patient/doctor relationship for the purpose of providing continuity of care;
• Establish hours of operation for treating patients at least 30 hours per week;
• Provide access to medical advice/services 24/7;
• Maintain hospital admitting privileges or have a formal agreement with another doctor based on ages of the members accepted;
• Refer or authorize services to other providers when the service cannot be provided by the PCP;
• Use reports provided by the DMA managed care section as guides in maintaining the level of care that meets the goals of CCNC and patient needs.

However, practices participating in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program must achieve NCQA Recognition. Furthermore, participating practices in the seven demonstration counties must also achieve Blue Cross Blue Shield North Carolina (BCBSNC) Blue Quality Physician Program recognition by September 2013.

Definition: Chapter 590 of the 2009 Oregon Laws statutorily defines “primary care home” as a delivery system that promote the minimum elements:

• A patient-provider relationship at the center of all health care activities;

• Patient access, including same-day visits;

• A team approach to care, with all team members utilizing the full scope of their license;

• Behavioral health integration (need not be colocation);

• Culturally competent care, with translation and other culturally sensitive services provided as necessary;

• Managed and coordinated care across the community services system;

• Proactive, comprehensive care

• Expanded nursing roles, including, but not limited to: care coordination; telephone outreach; school-based health; home visits; telephone triage and clinical case management; and coordination of information-sharing among community providers;

• Patient accountability for adhering to said patient’s health goals; and

• Efficient and timely case management for managing chronic diseases, behavioral health and end-of-life care.

Recognition: The Standards Advisory Committee enumerated the core attributes and standards (standards in parenthesis) of a PCPCH as follows:

1. Access to Care (In-person, Telephone/electronic, Administrative)

2. Accountability (Performance Improvement, Cost and Utilization)

3. Comprehensive Whole Person Care (Scope of Services)
   

4. Continuity (Provider, Information, Geographic)

5. Coordination and Integration (Data management, Care coordination, Care planning)

6. Person and Family Centered Care (Communication, Education and self-management support, Experience of Care)

See the full report for more information.

Oregon’s recognition model is similar to NCQA, incorporating three tiers of recognition, but the state developed recognition criteria are not identical. However, Oregon will recognize NQCA-recognized practices at the NCQA tier, provided that the practice contractually attests to NCQA recognition and submits additional information on specific areas where the two recognition models diverge. See the implementation guide for more information.

CEDARR (Comprehensive Evaluation Diagnosis Assessment Referral Re-evaluation) Family Centers are expected to meet state-developed certification standards that are available online. Additional standards specific to serving as a 2703 health home, such as using health information technology (IT) and conducting regular body mass index (BMI) screenings, have also been developed.

1. provide comprehensive prevention and disease screening for his or her patients and managing his or her patients’ chronic conditions by coordinating care;
2. enable patients to have access to personal health information through a secure medium, such as through the Internet, consistent with federal health information technology standards;
3. use a uniform assessment tool provided by the Blueprint in assessing a patient’s health;
4. collaborate with the community health teams, including by developing and implementing a comprehensive plan for participating patients;
5. ensure access to a patient’s medical records by the community health team members in a manner compliant with federal and state law; and
6. meet regularly with the community health team to ensure integration of a participating patient’s care.

Recognition: NCQA PCMH recognition

1. Demonstrated leadership;
2. Team-based approach to care;
3. Population risk stratification and management;
4. Practice-integrated care management;
5. Enhanced access to care;
6. Behavioral-physical health integration;
7. Connection to community resources;
8. Commitment to reducing unnecessary health care spending, reducing waste, and improving cost-effective use of health care services;
9. Integration of health information technology; and
10. Inclusion of patients and families in implementation of the patient-centered medical home (PCMH) model.