March 2015 Newsletter

Creating Medical Home About Improvement, Not Checking Boxes


An insightful blog post from the American Academy of Family Physicians' (AAFP) vice president of advocacy and practice advancement advises primary care physicians to not consider Patient Centered Medical Home (PCMH) practice redesign and PCMH recognition as synonymous.


He encourages "every family physician to transform your practice based on the principles of the PCMH," and to "consider third-party PCMH designation if that is beneficial to your practice" and "if it is supported by a business case in your practice or local market, meaning there are payment incentives available."


He writes that PCMH should be focused on "process improvement, quality improvement, team-based and patient-centric care, and reform at a pace that benefits your patients and your practice," not on "a collection of chart extractions, screen captures, and checklists."


He recommends the AAFP's PCMH Planner as a tool to help practices move toward a medical home. PA SPREAD also has a variety of resources available to assist in PCMH advancement.

Practice-Based Care Coordination Proves Valuable for 

Patient, Providers        


One of the more daunting and expensive principles for a PCMH to meet may be coordinating care across all elements of the complex health care system.


The Agency for Healthcare Research and Quality  (AHRQ) says care coordination "involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care [including the patient] to achieve safer and more effective care." As such, AHRQ says the two fundamental goals of care coordination are to transfer information and establish accountability.


Care coordinators typically offer the following types of assistance:

  • Answer phone calls from patients/families and assess/address needs.
  • Develop and implement care plans and evaluating the effectiveness of interventions.
  • Manage referrals and linkages with specialists and other health care and community resources.
  • Provide patient/family education.
  • Link patients/families with other patients/families for support.
  • Help patients/families organize and track medical information.
  • Coordinate coverage issues with insurers.
  • Connect with patients following hospitalizations or emergency department visits to assess needs and assure plans for follow-up care.

Sample care plans and care coordinator training resources are offered through Group Health's MacColl Institute for Healthcare InnovationMedical Home Learning Collaborative (pediatric-focused, but easily adapted for adult care), Alberta Health Services Self-Management and Complex Care Planning Workbook, Minnesota Department of Health, Washington State Medical Home Partnerships Project, and National Transitions of Care Coalition.


It is important to note that care coordination is different from complex care management. Many patients need some level of care coordination at some point in their life, whereas complex care management is a risk-stratified approach to provide disease management and self-management support for very high-risk patients.


As such, medical assistants, trained laypersons, social workers, and others can make excellent care coordinators. Complex care managers are usually RNs.

Best Practices Spotlight

An exemplary practice profiled in Robert Wood Johnson Foundation's LEAP Initiative, has created a specialty referral request checklist. This checklist enables health professionals to have all of the information on one patient across the spectrum of services. This can include community resources, specialists, labs, emergency departments, and hospitals.


By making changes to the referral system in a practice, patients and health providers alike know what services a patient needs, when they need them, and when they had access to them. A template also places accountability with team members involved in the referral process.

In The Literature


National surveys of small/medium and large primary care practices found 40% increased use of medical home processes between the 2007-2009 time frame and 2012-2013 for patients with asthma, congestive heart failure, depression, and diabetes.


The 5 PCMH processes that increased the most in both groups of practices were related to the use of EMRs for quality improvement, clinical decision support, and care coordination.


Small/medium sized practices increased more than large practices in the areas of (1) use of nurse care managers for chronic conditions, (2) use of nonphysician staff for patient education, (3) use of patient reminders for preventive care and follow-up for conditions, and (4) physician communications with patients by e-mail.


Large practices increased more in the use of quality improvement collaboratives and plan-do-study-act cycles. Mixed usage results were found in having electronic access to ED and hospital discharge information, providing group visits for patients, and providing feedback to physicians on quality of care. Both groups saw declines in incorporating patient feedback on care, a concern considering the importance of patient engagement and activation in the PCMH.

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