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Chapter 595 of the 2009 Oregon Laws established the Oregon Patient-Centered Primary Care Home (PCPCH) Program within the Office for Oregon Health Policy and Research (OHPR). The law required OHPR to:

  1. Define core attributes of the patient centered primary care home;

  2. Establish a simple and uniform process to identify patient centered primary care homes that meet the core attributes;

  3. Develop uniform quality measures (including acute-care hospital and ambulatory measures) that build from nationally-accepted measures and allow for standard measurement of performance;

  4. Develop policies that encourage the retention of, and the growth in the numbers of, primary care providers.

Chapter 602 of the 2011 Oregon Laws, creating the Oregon Integrated and Coordinated Health Care Delivery System in which Coordinated Care Organizations (CCOs) deliver care to medical assistance beneficiaries and dual eligibles. This law requires the Oregon Health Authority (OHA) to establish standards for using PCPCHs within CCOs and requires CCOs to implement PCPCHs to the extent possible. Standards may require the use of FQHCs, rural health clinics, school-based health clinics and other safety net providers that qualify as PCPCHs.

 

In September 2011, Oregon submitted a State Plan Amendment (SPA) to implement health homes under Section 2703 of the Affordable Care Act (ACA)

 

Targeted Population: All Oregonians.

 

Last Updated: September 2011

 

Forming Partnerships

Chapter 595 of the 2009 Oregon Laws created a 15-member advisory committee and required a diverse constituency (e.g., payers, practices, third-party administrators) guided by public input. In fact, the Director of the Oregon Health Authority convened two advisory committees: a Standards Advisory Committee and the Pediatric Standards Advisory Committee.

 

More recently, OHA has partnered with the Northwest Health Foundation (NWHF) to convene the NWHF PCPCH Task Force. The task force, made up of clinicians (both primary care and mental health), patients, public health experts, and healthcare delivery technical experts, will develop recommendations and action steps to support broad implementation of Patient-Centered Primary Care Homes (PCPCH) in the state.

Defining & Recognizing a Medical Home

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.

Aligning Reimbursement & Purchasing

Chapter 595 of the 2009 Oregon Laws authorized Medicaid reimbursement for Patient-Centered Primary Care Home (PCPCH) services. The law also authorized reimbursement for interpretive services provided to medical assistance beneficiaries if such services qualified for federal financial participation.

A learning collaborative created by the law was charged with coordinating efforts to develop and test methods to align financial incentives to support PCPCHs. Chapter 595 also provided Parker antitrust immunity to public payers, private health carriers, third party purchasers and providers, allowing collaboration to identify appropriate reimbursement methods to align incentives in support of patient centered primary care homes.

Chapter 590 of the Acts of 2009 required that, if feasible, the PCPCH reimbursement system include:   

  • Valuing services performed by nurses and behaviorists;

  • Payment for the establishment and use of team-based care

  • Preventive, educational, diagnostic care, care management and follow-up social services coordination; and

  • Home visits for case management services

Chapter 590 also granted the Department of Human Services authority to develop additional incentive payments to transform the current primary care delivery system and improve the population’s health outcomes, such as:

  • Integrating primary, oral and behavioral health care;

  • Utilizing evidence-based best practices;

  • Improving health outcomes; and/or

  • Learning collaborative participation.

Oregon plans to reimburse providers for currently care coordination services that were previously non‐reimbursable. The Oregon Health Policy Board has directed the Oregon Health Authority to pursue innovative payment methodologies. Such innovative payment methodologies must:

  • Provide financial support for meeting PCPCH standards;

  • Recognize the three levels of PCPCH tiering; and

  • Base reimbursement on the quality rather than the quantity of services provided.

If an MCO or carrier does not pursue an innovative payment arrangement, a specific additional payment is made to practices meeting PCPCH criteria. This payment corresponds to the PCPCH Tier for which a practice qualifies (Tier 3 > Tier 2 > Tier 1). When developing the payment rate, the MCO and/or carrier must consider the costs practices incur for meeting the PCPCH criteria, including, but not limited to:

  • Electronic medical record implementation and upgrade;

  • Care coordination; and

  • Dedicated time to quality improvement.

Supporting Practices

Chapter 595 of the 2009 Oregon Laws required OHPR to establish a learning collaborative for state agencies, payers, providers, and third party administrators to: 

  1. Share information about quality improvement;
  2. Share best practices that increase access to culturally competent and linguistically appropriate care;
  3. Share best practices that increase the adoption and use of the latest techniques in effective and cost-effective patient centered care;
  4. Coordinate efforts to develop and test methods to align financial incentives to support patient centered primary care homes;
  5. Share best practices for maximizing the utilization of patient centered primary care homes by individuals enrolled in medical assistance programs, including culturally specific and targeted outreach and direct assistance with applications to adults and children of racial, ethnic and language minority communities and other underserved populations;
  6. Coordinate efforts to conduct research on patient centered primary care homes and evaluate strategies to implement the patient centered primary care home to improve health status and quality and reduce overall health care costs; and
  7. Share best practices for maximizing integration to ensure that patients have access to comprehensive primary care, including preventative and disease management services

Measuring Results

Chapter 595 of the 2009 Oregon Laws requires practices receiving Patient-Centered Primary Care Home (PCPCH) reimbursement to report quality measures specified by OHPR. Proposed PCPCH measures vary by tier, and can be found in Appendices C and D of the Standards Advisory Committee’s final report.

Under the upcoming Integrated and Coordinated Health Care Delivery System, CCOs will be required to report uniform quality measures for PCPCHs to OHA.

PCPCH efforts will be included in a statewide scorecard to measure success for the Action Plan for Health across the OHA lines of coverage as well as statewide.