NCQA PCMH Recognition: Where to Begin · 2018. 6. 20. · NCQA PCMH Recognition: Where to Begin . ... • Identify Staff leaders who will assist physician and staff in obtaining data

NCQA PCMH Recognition: Where to Begin

What is Patient-Centered Medical Home?

The patient-centered medical home is a model of care that puts patients at the forefront of care. PCMHs build better relationships between people and their clinical care teams.

Research shows that PCMHs: • Improve quality. Patients get the treatment they need, when they need it. • Reduce costs. They prevent expensive and avoidable hospitalizations; emergency room visits an complications— especially for patients with complex chronic conditions. • Improve the patient experience. They provide the personalized, comprehensive coordinated care that patients want. • Improve staff satisfaction. Their systems and structures help staff work more efficiently. NCQA helps primary care practices transform into a medical home through its PCMH Recognition program. http://ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx Commit: Plan

• Identify a physician leader who can direct your practice transformation. Qualities include: o Interested in quality improvement o Able to motivate other providers o Able to supervise and direct staff

• Establish those individuals authorized to approve policies, protocols and procedures in each practice as not to impede progress.

• Will need at least one person who is allotted to working on the recognition project. • Identify Staff leaders who will assist physician and staff in obtaining data and designing process changes. These

may include: o Project coordinator o Nursing supervisor o Insurance personnel o Information Technology support o Office Manager and/or Practice Administrator o Identify the care team

• What Electronic Health Record are you using? • What practice management system are you using? • What are your report running capabilities? • Are you working on any quality improvement projects? If so, what are they? • Do you have a Policy and Procedure Manual? If not, need to document policies and processes/procedures

throughout the practice. • Do you have a patient survey? • What population outreach activities are you doing? • Do you hold regular staff education sessions (either at monthly staff meetings or in-services) on how to work

with the patient population? Commit: Review

• Q-PASS: Your NCQA Recognition process is managed through the Quality Performance Assessment Support System (Q-PASS). You will use this web-based platform to submit information to NCQA. Q-PASS lets you manage multiple organizations, practices, clinicians and recognitions through a single portal.

• Download the 2017 NCQA PCMH Standards or ask your designated PCMH Provider Performance Consultant (PPC) for assistance.

• Read and study the guidelines • Review the NCQA Toolkit • How many practices are included? • Do they share the same EHR? • Do they share the same policies and procedures?

http://ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx

• Can one person sign agreements for all practices included? • Determine whether a multisite or individual site application is appropriate.

Transform: Prepare Application

• Begin working with your PPC to develop a roadmap/timeline for your PCMH journey that best meets your practices setup and culture. (Culture will need to transform to a patient centered culture)

• Adjust roadmap/timeline as needed. Resources:

• Sign up at www.my.ncqa.org to ask NCQA questions. • Watch online training videos (schedule found at

http://ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx)

NCQA Recognition timeline

PPC meets with practice for intial PCMH Kick OffPPC emails Self-Assessment Tool (need to reassess to see if new one comes out.)PPC meets with Project Team and Practice Managers to review Assessment ToolPPC and Practice create a roadmap/timeline for their practice to implement andtransform to a PCMH.

Month 1

•PPC meets with practice to review practices current policies and procedures

Month 2

•PPC meets with Practice to review Standard 1A- C and begin working on it

Month 3

•PPC meets with Practice to review Standard 1A-C documentation and discuss Guideline 2A-D

Month 4

•PPC meets with practice to review Standard 2A-D documentation and begin discussing Standard 6A-G

Month 5•PPC meets with Practice

to discuss Standard 3A-E and begin working on it. Purchase Survey Tool(s)

Month 6

•PPC meets with practice to review documentation on 3A-E and begin working on Standard 4A-C and continue discussion 6A-G

Month 7

•PPC meets with practice to review Standard 4A-C documentation and begin discussion on Standard 5A-C

Month 8

•PPC meets with practice to review Standard 5A-C documentation and begin working on 6A-G

Month 9

•PPC meets with practice to review and continue working on 6A-G

http://www.my.ncqa.org/

http://ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx

Table 1: Summary of NCQA PCMH Standards

Concept Brief Concept Description

Team-Based Care and Practice Organization (TC)

The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.

Knowing and Managing Your Patients (KM) The practice uses information about the patients and community it serves to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.

Patient-Centered Access and Continuity (AC) The practice provides 24/7 access to clinical advice and appropriate care facilitated by their designated clinician/care team, considers the needs and preferences of the patient population when modeling standards for access.

Care Management and Support (CM) The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

Care Coordination and Care Transitions (CC) The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations.

Performance Measurement and Quality Improvement (QI)

The practice establishes a culture of data-driven performance improvement on clinical quality, efficiency and patient experience, and engages staff and patients/families/ caregivers in quality improvement activities.

Succeed: Maintain Recognition

• Each year, the practice checks in with NCQA to show its ongoing activities are consistent with the PCMH model of care. • This is part of the Annual Reporting process and includes attesting to certain policies and procedures and submission of some

data. • This process sustains the practice’s recognition and fosters continuous improvement. That means the practice succeeds in

strengthening its transformation and, as a result, patient care. • NCQA has the only national program that supports ongoing quality improvement in this way.

Characteristics of Patient-Centered Medical Home Initiativesthat Generated Savings for Medicare: a Qualitative Multi-CaseAnalysisRachel A. Burton, MPP1, Nicole M. Lallemand, MPP1, Rebecca A. Peters, MPH1, andStephen Zuckerman, PhD1, The MAPCP Demonstration Evaluation Team1,2,3,4

1The Urban Institute,Washington,DC, USA; 2RTI International, Research Triangle Park, NC, USA ; 3National Academy for State Health Policy, Portland,ME, USA ; 4The Henne Group, San Francisco, CA, USA .

BACKGROUND: Through the Multi-Payer Advanced Pri-mary Care Practice (MAPCP) Demonstration, Medicare,Medicaid, and private payers offered supplemental pay-ments to 849 primary care practices that became patient-centered medical homes (PCMHs) in eight states; prac-tices also received technical assistance and data reports.Average Medicare payments were capped at $10 per ben-eficiary per month in each state.OBJECTIVE: Since there was variation in the eight par-ticipating states’ demonstration designs, experiences,and outcomes, we conducted a qualitative multi-caseanalysis to identify the key factors that differentiatedstates that were estimated to have generated net savingsfor Medicare from states that did not.PARTICIPANTS: States’ MAPCP Demonstration initia-tives were comprehensively profiled in case studies basedon secondary document review, three rounds of annualinterviews with state staff, payers, practices, and otherstakeholders, and other data sources.APPROACH: Case study findings were summarized in acase-ordered predictor-outcome matrix, which identifiedthe presence or absence of key demonstration design fea-tures and experiences and arrayed states based on theamount of net savings or losses they generated for Medi-care. We then used this matrix to identify initiative fea-tures that were present in at least three of the four statesthat generated net savings and absent from at least threeof the four states that did not generate savings.RESULTS: A majority of the states that generated netsavings: required practices to be recognized PCMHs toenter the demonstration, did not allow late entrants intothe demonstration, used a consistent demonstration pay-mentmodel across participating payers, and offered prac-tices opportunities to earn performance bonuses. Prac-tices in states that generated net savings also tended toreport receiving the demonstration payments and bo-nuses they expected to receive, without any issues.CONCLUSIONS:Designers of future PCMH initiativesmayincrease their likelihood of generating net savings by incor-porating the demonstration features we identified.

KEYWORDS:primary care redesign;Medicare; qualitative research;health

care costs; program evaluation.

J Gen Intern Med

DOI: 10.1007/s11606-018-4309-x

© Society of General Internal Medicine 2018

INTRODUCTION

Initiatives that encourage primary care practices to adopt thepatient-centered medical home (PCMH) model of care haveproliferated in recent years, under the expectation that offeringmore coordinated, accessible, patient-centered care will keeppatients healthy and out of the hospital—thus saving moneywhile improving patient health. Evaluations of these interven-tions have attempted to determine whether the PCMH modellives up to this promise.1

So far, the results have been mixed. Some PCMH evalua-tions have found evidence of improvements in patient and staffexperiences, preventive services delivery, patient safety, andreductions in emergency department use.2–5 Other studies haveidentified improved outcomes among patient populations thatare sicker than the general patient population (e.g., patients withchronic conditions, children with special needs, older pa-tients).6–9 Despite some encouraging trends when looking athealth care quality measures, evaluations generally providemixed or inconclusive evidence of cost reductions.1,4,9–12

In an effort to learn more about this delivery reform, theCenters for Medicaid & Medicare Services (CMS) sponsoredthe Multi-Payer Advanced Primary Care Practice (MAPCP)Demonstration, through which Medicare joined state-run,multi-payer PCMH initiatives underway in eight states.Demonstration payments—ultimately totaling nearly $125million—supported the provision of patient-centered, com-prehensive, coordinated care and enhanced access. Moreproductive provider-patient interactions were expected tolead to improved functional and clinical outcomes, whichin turn were expected to produce more efficient healthservice utilization patterns.13 The MAPCP Demonstrationbegan in late 2011 and ran through 2014—which is theperiod we analyze in this article—and was then extended

Electronic supplementary material The online version of this article(https://doi.org/10.1007/s11606-018-4309-x) contains supplementarymaterial, which is available to authorized users.

Received July 7, 2017Revised December 1, 2017Accepted December 28, 2017

http://dx.doi.org/10.1007/s11606-018-4309-x

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until the end of 2016 in five states (Maine, Michigan, NewYork, Rhode Island, and Vermont).As part of the demonstration, 849 primary care practices

that became certified as PCMHs (using the National Commit-tee on Quality Assurance’s (NCQA’s) standards or comparablestate-specific standards) were eligible for supplemental pay-ments fromMedicare, Medicaid, and some private payers andalso received technical assistance and data reports. Demon-stration payments were intended to help practices pay forimprovements like hiring care coordinators, expanding theiroffice hours, staffing live after-hours phone lines, or enhancingelectronic medical records’ registry capabilities. Outside orga-nizations that supported or supplemented the care delivered bythese practices (e.g., community health teams in Vermont,which worked with practices to provide care coordinationand other supportive services to patients) also received dem-onstration payments in five states. Although states designedtheir own payment models, Medicare payments for practicesand other organizations were not supposed to exceed $10 perbeneficiary per month, on average; Medicaid and privatepayers were expected to use a similar approach for determin-ing payment amounts. (An online appendix provides detailson MAPCP Demonstration states’ payment models andPCMH practice recognition requirements.)Given the substantial variation in states’ demonstration

designs, experiences, and outcomes, we conducted a qualita-tive multi-case study to identify the key factors that differen-tiated states that generated net savings for Medicare fromstates that did not, since reducing costs is a critical aim of thiscare delivery model. This article is one of the first of its kind,since in the existing literature, comparisons of different PCMHinitiatives have typically focused on identifying the outcomesthat the overall PCMH model produces and have notattempted to identify initiative design features associated withsuccessful outcomes.1,2,7,9,14,15

METHODS

This qualitative multi-case analysis uses the Bcase-orderedpredictor-outcome matrix^ methodology to relate the keyfeatures of states’ MAPCP Demonstration initiatives to a keyperformance outcome and facilitate the identification of cross-state patterns.16 Here we focus on initiative features related toestimates of net savings to the Medicare program. We identifythe initiative features of each MAPCP Demonstration statefrom comprehensive case studies that summarized findingsfrom a variety of sources, including (but not limited to):researchers’ review of secondary documents (e.g., states’ dem-onstration applications and progress reports); three annualrounds of semi-structured interviews conducted in late 2012,2013, and 2014 with state staff, public and private payers, apurposive sample of staff from participating practices, andother stakeholders; and a provider survey fielded in early2015, which asked about the extent to which demonstration

practices engaged in 23 activities associated with the PCMHmodel.13 (Methodological approaches used to analyze variousdata sources are described in our final evaluation report; seeChapter 1.13) Data collection was approved by the InstitutionalReview Boards of RTI International and the Urban Institute,and informed consent was obtained from all interviewees andsurvey respondents.To avoid bias in selecting the initiative features we hypoth-

esized might influence a state’s ability to generate net savings,we reviewed the case studies prior to having final estimates ofthe key outcome. For example, in reviewing theMinnesota casestudy, it became clear that billing difficulties that preventedproviders from receiving demonstration payments was a majorissue according to interviewees, so we included billing issues asa feature we should assess in all eight of the MAPCP Demon-stration states. Once we had summarized the presence or ab-sence of each initiative feature to be studied, we had the leadresearcher evaluating each state review this information toensure we had accurately characterized each state’s initiative.We chose net savings for Medicare as our main outcome of

interest since it is an important measure to CMS and the publicand since it is a metric that all states were hoping to improvethrough the demonstration. States were classified as havinggenerated net savings if the Medicare beneficiaries attributedto their state’s demonstration practices were estimated to havelower total Medicare spending than beneficiaries attributed tocomparison practices, after taking into account the demonstra-tion payments practices received. The comparison practiceswere not recognized as PCMHs, but were located in compa-rable geographic areas within or near each of our demonstra-tion states.We estimated the effects of the demonstration on gross

Medicare savings (i.e., savings beforeMAPCP payments weretaken into account) using a state-specific difference-in-differences multivariate regression framework to comparechanges in Medicare spending among beneficiaries at demon-stration practices to changes among beneficiaries at compari-son group practices. (Details of this analysis are available inour final report; see Section 1.2.13) The regression model usedto calculate gross savings controlled for a number of benefi-ciary-, practice-, and area-level characteristics that could inde-pendently influence the amount of net savings generated by astate. (These characteristics are described in Section 1.2.5 ofour final report.13)If this model showed that increases in Medicare spending

were significantly smaller among beneficiaries at demonstra-tion practices than among comparison group beneficiaries, thismeant that the demonstration produced gross savings forMedicare. These savings were weighted by the respectivenumber of demonstration beneficiaries in the sample to pro-duce an aggregate estimate of gross savings (or losses) foreach state. Gross savings include total Medicare Parts A and Bspending; Medicare Part D spending on prescription drugswas not available to be included in these estimates. (Benefi-ciaries insured through Medicare Advantage plans were not

Burton et al.: Characteristics of MAPCP States with Savings JGIM

included in this demonstration and are therefore not includedin our estimates.)Once gross savings were calculated, the amount of MAPCP

Demonstration payments were subtracted from these amountsto derive net savings.We include both types of paymentsmadethrough this demonstration: payments to primary care prac-tices, as well as payments to organizations that supported orsupplemented practices’ activities, such as Vermont’s commu-nity health teams. Table 1 identifies the net savings generatedby each MAPCP Demonstration state; summing the eightstates’ financial performance during this period, we find thatthese states did not generate net savings for the Medicareprogram overall.With the estimates of net savings and the program features

hypothesized to be related to this outcome, we constructed aBcase-ordered predictor-outcome matrix.^ Moving from left toright in this matrix (Table 2), we arrayed states from best toworst performance, with the four states that generated netsavings for Medicare clustered at the left and the four states thatdid not clustered at the right.We use a solid black circle (B●^) toindicate that a characteristic was present in a state, we left tablecells blank if a characteristic was absent in a state, and we used ahollow white circle (B○^) when a factor was only partiallypresent. For example, in the BPractices had to be recognizedPCMHs when they entered the demonstration^ row, the hollowwhite circle (B○^) in the Maine column indicates that the firstcohort of practices that joined the demonstration was given a 6-month grace period to achieve NCQA PCMH recognition,while practices in a second cohort were required to have PCMHrecognition upon entry into the demonstration.One limitation of this study is that not all demonstration

states’ net savings or losses were statistically significant, so theordering in our matrix is based on these best available pointestimates of net savings. In addition, state-level factors that wecannot identify may confound the relationships between sav-ings and the features that we can identify. Had these limitationsnot been present, we would have greater confidence in theimportance of the factors identified in our matrix analysis.

However, this study is still useful in helping generate hypoth-eses that could be tested in future studies.

RESULTS

Factors Associated with Generating NetSavings

We considered factors to be associated with generating netsavings if they were present in at least three of the four statesthat generated net savings and absent from at least three of thefour states that did not generate savings. (These five factors areshown in the top third of Table 2).Our first finding was that most states with net savings did

not allow late entrants into the demonstration after the startdate, while a majority of the states that failed to generate netsavings did not have this requirement. In this latter set ofstates, the number of practices in these states’ demonstrationsincreased between 50% and 200% over the course of thedemonstration. If PCMH practices become more effectiveover time (e.g., by refining new workflows and care coordi-nator duties to best fit their practice needs), then it is possiblethat allowing new, less-experienced PCMHs practices to jointhroughout the demonstration period may have brought downoverall average impacts in states that did not generate netsavings.Once practices had joined a state’s demonstration and were

receiving payments, some states gave them a grace period of 6,12, or 18 months to obtain PCMH certification. We found thatmost of the states that generated net savings required practicesto be certified PCMHs when they entered the demonstration,while states that failed to generate net savings tended to allowpractices such a grace period. Practices that were alreadyoperational PCMHs at the beginning of their states’ demon-strations may have had a head start on developing and usingapproaches that could generate cost savings over the course ofthe demonstration. Meanwhile, practices that were allowed agrace period may have spent the early months of the

Table 1 Financial Results of the MAPCP Demonstration

State Total MAPCP demonstration fees paid ($) Gross savings ($)† Net savings ($)‡ Return on fees ($)§

Michigan 64,938,363 140,492,980 75,554,617 2.16Vermont 18,340,927 61,754,919* 43,413,993 3.37Pennsylvania 5,338,237 25,202,759 12,727,596 2.02New York 5,750,926 8,118,395 2,367,470 1.41Rhode Island 1,974,907 −9,354,522 −11,329,430 −4.74North Carolina 6,524,816 −14,733,773 −21,258,589 −2.26Maine 12,313,581 −71,508,160* −83,821,741* −5.81Minnesota 2,429,820 −85,495,768* −87,925,588* −35.19

MAPCP=Multi-Payer Advanced Primary Care Practice*Statistically significant at the 10% level† For gross savings, + = gross savings, and - = gross losses‡ Net savings =Gross Savings - Total MAPCP Demonstration Fees Paid§ Return on fees =Gross Savings ÷ Total MAPCP Demonstration Fees Paid. A value > $1.00 indicates a favorable return on the investment of MAPCPDemonstration fees; a value < $1.00 indicates an unfavorable returnSavings are relative to non-patient-centered medical home (PCMH) comparison practices. Only gross and net savings were tested for statisticalsignificance, and statistical testing was done only at the state level; statistical significance cannot be determined for the total gross or net savings acrossall states. Beneficiaries with < 3 months of Medicare eligibility during the demonstration were not used in the calculation of savings or fees paid

Burton et al.: Characteristics of MAPCP States with SavingsJGIM

demonstration trying to understand and adopt the PCMHmodel at a basic level rather than moving on to more advancedactivities like optimizing new care delivery approaches. Con-sistent with this observation, we found that by the end of thedemonstration, practices in states with net savings reportedengaging in an above-average share of the 23 PCMH activitiesincluded in our provider survey—reinforcing the idea thatthere may be a link between PCMH maturity and practices’ability to generate net savings.17

Our third finding is that in most of the states that weresuccessful in generating net savings, all participating payers’demonstration payment models incentivized performing aconsistent set of activities or treating a consistent type ofpatient (even if payers sometimes paid slightly differentamounts), whereas in most of the states that failed to generatenet savings, payers used more inconsistent payment models.For example, in Vermont (a state that generated net savings),all payers paid practices higher demonstration payments ifthey achieved higher NCQAPCMH recognition levels. Mean-while, in North Carolina (a state that did not generate savings),Medicare paid higher demonstration payments for higher

PCMH recognition levels, Medicaid made higher paymentsfor aged, blind, or disabled patients (regardless of what thepractice’s PCMH recognition level was), and private payersoffered an enhanced fee schedule that was actuarially equiva-lent to receiving an additional $1.50 per patient per month(regardless of the practice’s PCMH recognition level or thehealth of a patient).Another finding related to payment models was that in most

of the states that generated savings, participating payers of-fered practices the opportunity to earn a bonus if they metquality measure performance targets; in contrast, most of thestates that failed to generate savings did not offer such bo-nuses. (Descriptions of how performance bonuses were calcu-lated in these states are included in our online appendix; seeTable A-1).Finally, we found that in most of the states that achieved net

savings, demonstration participants tended to receive the pay-ments and bonuses they expected to receive. Meanwhile, in amajority of the states that did not generate net savings, this wasnot the case. In Minnesota, where the state required practicesto submit new claims to fee-for-service Medicare and

Table 2 Factors Present in States that Did or Did Not Generate Net Savings for Medicare

Net savings for Medicare?

Yes No

MI VT PA NY RI NC ME MN

Factors associated with generating net savings*No late entrants allowed after the demonstration start date ● ● ● ●Practices had to be recognized PCMHs when they entered the demonstration(no grace period to obtain PCMH recognition)

● ● ● ○ ●

All payers’ demonstration payment models incentivized consistent activities within a state ● ● ● ●Payers’ demonstration payment models included opportunities for practices to earnperformance bonuses

● ● ● ●

Demonstration participants received the demonstration payments and bonuses theyexpected to receive

● ● ● ●

Factors that may be necessary but not sufficient to generate net savings†A precursor PCMH initiative offered payments to practices ● ● ● ● ● ● ● ●Payers participated voluntarily in the MAPCP Demonstration ● ● ● ● ● ●Leaders of state government supported the demonstration ● ● ● ● ● ● ●Stakeholders and physicians supported the demonstration ● ● ○ ● ● ○ ● ●Complementary payment and care delivery reforms underway ● ● ● ● ● ● ● ●Most practices met NCQA’s PCMH recognition standards (as opposed to another entity'sPCMH recognition standards)

● ● ● ● ● ●

Care coordinators focused on high-risk patients ● ● ● ● ○ ● ● ●Factors not associated with net savings‡A large number of practices participated (> 100 practices) ● ● ●Practices were only required to recertify as PCMHs every 3 years (instead of morefrequently—e.g., every 12–18 months)

● ● ● ● ●

Practices were required to offer round-the-clock access to care ● ● ●Other organizations received demonstration payments to support/supplement practices’activities (e.g., Physician Organizations in MI, Community Health Teams in VT)§

● ● ● ● ●

Technical assistance was viewed positively by practices ○ ● ○ ● ○ ● ● ●Technical assistance targeted to care coordinators was offered ● ● ● ○ ● ○Care coordinators tended to be employed by practices (as opposed to a health system oroutside entity)

● ○ ● ● ○

Care coordinators tended to be nurses (as opposed to individuals with less clinical training) ● ● ● ● ● ○Practices regularly received hospital discharge data or alerts ● ○ ○ ○ ○ ○ ○

● = factor is present in state; ○ = factor is partially present in state; empty cell = factor is not present in state; MAPCP=Multi-Payer AdvancedPrimary Care Practice; PCMH= patient-centered medical home*These factors were present in ≥ 3 of the 4 states that generated net savings and absent from ≥ 3 of the 4 states that did not generate savings† These factors were present in ≥ 3 of the 4 states that generated net savings and ≥ 3 of the 4 states that did not generate savings‡ These factors did not meet either of the prior two criteria, suggesting that they may not have a relationship with net savings§ The payment methodologies used in these five states are described in our online appendix


Medicaid to receive demonstration payments, billing was socumbersome (and the costs to modify billing systems so steep)that many practices reported it was not worth the effort.1 InNorth Carolina, a change in state vendors resulted in months-long delays in Medicaid demonstration payments. And inMaine, Medicaid changed its payment model for communitycare teams (a demonstration-funded organizationsupplementing practices’ activities) midway, switching frommaking payments for all of a practices’ patients to onlyfunding services for the 5% that were highest risk. In thesestates, not receiving the payments they expected seemed tomake it more difficult for participants to plan, invest in, andimplement activities designed to maintain or strengthen theiradoption of the PCMH model. This was despite the fact thatproviders interviewed in all eight states usually reported thatdemonstration payments were not generous enough to coverthe full cost of changes they had made (e.g., hiring newstaff).

Factors that May Be Necessary but NotSufficient to Generate Net Savings

Another set of factors in our matrix was present in at least threeof the four states that generated net savings and at least three ofthe four states that did not generate net savings (see middlethird of Table 2). We interpret factors present in a majority ofthe states that generated net savings as being necessary; how-ever, since these factors were also present in a majority of thestates that did not generate net savings, they are not sufficientto distinguish these two groups of states.These widely observed factors were as follows: a pilot

PCMH initiative offered payments to practices before theMAPCP Demonstration; payers participated voluntarily inthe demonstration (as opposed to being required to participateby the state); the demonstration enjoyed support from leadersin state government (e.g., state staff were available to work onthe demonstration throughout the demonstration period andwere not redirected onto other projects); it also enjoyed sup-port from physicians and stakeholders (e.g., these stakeholdersviewed their state’s demonstration favorably after helping todevelop the PCMHmodel used in their state); complementarypayment and care delivery reforms were underway at the sametime as the demonstration (e.g., some payers were enteringinto shared savings contracts that incentivized practices to

more closely manage high-cost patients); practices were re-quired to meet NCQA’s PCMH practice recognition standards(as opposed to some other entity’s standards); and care coor-dinators tended to focus on high-risk patients.

Factors Not Associated with Net Savings

There were several factors whose presence or absence in theMAPCP Demonstration states did not suggest a relationshipwith states’ net savings performance (shown in the bottomthird of Table 2). Examples of these factors include: thefrequency with which practices had to recertify as PCMHs(which ranged from every 1 to 3 years); whether or not statesrequired practices to offer round-the-clock access to care;whether or not states paid other organizations to supportpractices (e.g., through ongoing data analytics or staff training)or to supplement practices’ activities (e.g., by offering addi-tional care management or counseling to patients); the em-ployment arrangements used for care coordinators (with prac-tices primarily employing them directly vs. third parties likelarger health systems embedding their own care coordinatorsinto practices); the professional background of care coordina-tors (who could be registered nurses or staff with less clinicaltraining, such as social workers or medical assistants).

DISCUSSION

Proponents of the PCMH model may find encouragement inour observation that the longer a practice has been operating asa PCMH, the more likely they are to generate netsavings—suggesting that the PCMH model can succeed, butit takes time (and the proper conditions) to do so. Considerableeffort and resources have been expended developing PCMHpractice recognition standards by a variety of accreditingorganizations and payers, designing and funding PCMH dem-onstrations and pilots, and evaluating these efforts. Our find-ings suggest that these efforts have not been in vain—butfuture multi-payer PCMH initiatives should pay special atten-tion to practice entry requirements, and to payment models’structure, consistency, and disbursal mechanisms, if generat-ing near-term net savings is a priority. Ultimately, our studysuggests that it may take more than 3 years for PCMH initia-tives to generate net savings—suggesting that longer timehorizons may be appropriate when conducting and evaluatingPCMH initiatives.Our finding about the importance of participating payers

aligning their payment models to incentivize consistent practiceactivities could be difficult to implement in practice. Multi-payer initiatives often seek voluntary participation from payers,who may each have their own preferred payment methodology.Payers may also be reluctant to join forces because of anti-trustconcerns or to protect proprietary details of their paymentmodel. Initiatives like CMS’s Comprehensive Primary CarePlus model have attempted to get around these obstacles bypublicly specifying a recommended payment model and then

1 Some Minnesota payers required practices to generate and submit monthlyclaims for each eligible demonstration patient rather than paying practices asingle monthly lump sum encompassing all of the demonstration fees for apractice’s attributed patients. This approach was burdensome enough thatmany practices chose to forego demonstration payments entirely. In interviews,Minnesota providers often told us that their billing systems were not set up togenerate a claim without a face-to-face visit, and the costs to modify theirbilling systems exceeded their expected revenues from these demonstrationpayments. Meanwhile, some Minnesota payers offered providers ACO sharedsavings-style contracts, which rewarded providers for reducing their totalspending and thus gave them a disincentive to collect demonstration fees fromthese payers.


evaluating payer applications based on the extent to which theyalign with CMS’s model.18 Some states, in turn, have issuedexecutive orders or passed legislation allowing payers to coop-erate as part of multi-payer PCMH initiatives.19 CMS’s StateInnovation Models (SIM) Initiative is also attempting to bringpayers together at the state level to get them to agree on aconsistent payment model to use.20

The issues we identified related to the disbursal of demon-stration payments seem quite important. In interviews, dem-onstration participants complained when they encounteredissues that prevented them from receiving agreed-upon pay-ments on time. Payers should recognize that most physiciansin the US still work in small practices21 and that disruptingpractices’ expected monthly cash flow can have major impactson their ability to meet payroll obligations, especially whenthey have hired new staff, such as care coordinators.Finally, our results suggest that the field still has much more

to learn about the optimal design of a PCMH initiative—thereis a considerable need for further experimentation to identifyadditional features that make a difference in a PCMH inter-vention’s ability to generate favorable outcomes. Future sys-tematic reviews of PCMH evaluations could use similar cross-case analysis methods to identify additional features that arepresent in successful initiatives and absent in unsuccessfulones.2 Future studies could also examine whether larger netsavings can be generated when a wider range of providers isincentivized to more closely manage their high-risk patients’care, such as through accountable care organizations (ACOs)that involve specialists and hospitals.

Limitations

We note that this multi-case study is not exhaustive, and otherunobserved or unidentified factors may explain the net savingsperformance observed in theMAPCPDemonstration (e.g., theshare of each practice’s patient panel included in the demon-stration, or practice capacity upon entry to the demonstration).Also, several factors included in our analysis are based onfindings from interviews conducted with purposive samples ofparticipating practices and other individuals in each state; ourinterviews are therefore not necessarily representative of theexperiences of the full universe of practices and individualsinvolved in each state’s demonstration initiative. We also notethat our study only included eight states; it is possible that astudy involving a larger number of participating states mayhave uncovered different findings.

Acknowledgements:

This article draws on data collected and analyzed by the MAPCPDemonstration Evaluation Team, which is made up of the fouridentified authors plus the following additional researchers, whoworked at four organizations: RTI International: Donald Nichols,Susan Haber, Melissa Romaire, Joshua Wiener, Musetta Leung, Kevin

Smith, Nathan West, Asta Sorensen, Kathleen Farrell, Leila Kahwati,Pamela Spain, Ellen Wilson, Noëlle Richa Siegfried, Amy Kandilov,Vincent Keyes, Chris Beadles, Carol Urato, Will Parish, Ann Larsen,Thomas Morgan, Jerry Cromwell, Stephanie Kissam, Lisa Lines,Patrick Edwards, Shellery Ebron, Rebecca Perry, Emily McClure,Mark Graber, Yiyan (Echo) Liu, Benjamin Koethe, Jenna Brophy,Andrew Kueffer, Amy Mills, Denise Clayton, Rebecca Lewis, SarahArnold, Sophia Kwon, Konny Kim, Lauren Komp, Aleksandra Petrovic,Kent Parks, Rose Feinberg, Timothy O’Brien, Matt Urato, Alon Evron,Elise Hooper, Huiling Pan, Heather Beil, Laxminarayana Ganapathi,Rui Guo, Michael Miles, Richie Thomas, Roger Osborn, Brett Ander-son, Emily Warmoth Thomas, Nick Kinsey, Tracy Wills, Elena Bravo-Taylor, John Shadle, Celia Eicheldinger, Laura Dunlap, VanessaThornburg, Renee Sullender, Lexie Grove, Lindsay Morris, BetsyPleasants, Magdalena Ignaczak, Wayne Anderson, Nancy McCall,Martijn Van Hasselt, Doug Raeder, Brendan DeCenso, MeghanHoward, Rachel Bidgood, Douglas Kamerow, Heather Pearson,Heather Kofke-Egger, Christina Villella, Carolyn Reyes Guzman,Nancy Berkman, Barbara Dalberth, Joshua Manning; The UrbanInstitute: Robert A. Berenson, Kelly J. Devers, Amanda Napoles,Arnav Shah; The National Academy for State Health Policy:Katie Dunn, Kathy Witgert, Neva Kaye, Charles Townley, RachelYalowich, Amy Clary, Mary Takach, Diane Justice, Barbara Wirth,Anne Gauthier, Karen VanLandegham, Michael Stanek, Sarah Kinsler,Jason Buxbaum, Lynn Dierker, Mary Henderson, Larry Hinkle, KittyPurington; The Henne Group: Jeff Henne.

Prior presentations: This analysis was presented as a podium pre-sentation at AcademyHealth’s State Health Research and Policy Inter-est Group Meeting on June 24, 2017, in New Orleans, and as a posterat AcademyHealth’s Annual Research Meeting, also in New Orleans,on June 26, 2017.

Corresponding Author: Rachel A. Burton, MPP; The Urban Institute,Washington, DC, USA (e-mail: [email protected]).

Funder This analysis was conducted as part of the evaluation of theMAPCP Demonstration and was funded by CMS through contract#HHSM-500-2010-00021i. The authors wish to thank SuzanneWensky and Jody Blatt at CMS for their insightful comments andsuggestions. However, the contents of this publication are solely theresponsibility of the authors and do not necessarily represent theofficial views of the US Department of Health and Human Services orany of its agencies.

Compliance with Ethical Standards:

Conflict of Interest:Each authordeclares that they have no conflict ofinterest.

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Medical Home. Closing the Quality Gap: Revisiting the State of theScience. Rockville (MD): Agency for Healthcare Research and Quality(AHRQ); 2012 July. Available at: https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/patient-centered-medical-home_research.pdf.Accessed December 13, 2017.

2. Hoff T, Weller W, DePuccio D. The Patient–Centered Medical Home: Areview of recent research. Med Care Res Rev. 2012;69(6):619-644.

3. Hadland S, Long W. A systematic review of the medical home for childrenwithout special health care needs. Matern Child Health J. 2014;18(4):891-8.

4. Arend J, Tsang-Quinn J, Levine C, Thomas D. The Patient-CenteredMedical Home: History, components and review of the evidence. Mt SinaiJ Med. 2012;79(4):433-50.

5. David G, Gunnarsson C, Saynisch P, Chawla R, Nigam S. Do Patient-Centered Medical Homes reduce emergency department visits? HealthServ Res. 2015;50(2):418-39.

6. Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers D. EarlyEvidence on the Patient-Centered Medical Home. Rockville (MD): AHRQ;

2 For example, CMS has hired a contractor to conduct such an analysis of itsvarious primary care demonstrations and initiatives.


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2012. Available at: https://pcmh.ahrq.gov/sites/default/files/attach-ments/Early%20Evidence%20on%20the%20PCMH%202%2028%2012.pdf. Accessed December 13, 2017.

7. DePuccio MJ, Hoff TJ. Medical home interventions and qualityoutcomes for older adults: A systematic review. Qual Manag Health Care.2013;22(4):327-40.

8. Homer C, Klatka K, Romm D, et al. A review of the evidence for themedical home for Children with Special Health Care Needs. Pediatrics.2008;122(4):e922-37.

9. Jackson G, Powers B, Chatterjee R, Bettger J, Kemper A, HasselbladV. The Patient-Centered Medical Home: A systematic review. Ann InternMed. 2013;158(3):169-78.

10. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Earlyevaluations of the medical home: Building a promising start. Am J ManagCare. 2012;18(2):105-16.

11. Fontaine P, Flottemesch TJ, Solberg LI, Asche SE. Is consistentprimary care within a patient-centered medical home related to utilizationpatterns and costs? J Ambul Care Manage. 2011;34(1):10-9.

12. Rosenthal T. The medical home: growing evidence to support a newapproach to primary care. J Am Board Fam Med. 2008;21(5):427-440.

13. Nichols D, Haber S, Romaire M, et al. Evaluation of the Multi-PayerAdvanced Primary Care Practice (MAPCP) Demonstration: Final Report.Baltimore: Centers for Medicare & Medicaid Services (CMS); 2017.Available at: https://downloads.cms.gov/files/cmmi/mapcp-finalevalrpt.pdf. Accessed December 13, 2017.

14. Edwards ST, Bitton A, Hong J, Landon B. Patient-centered medicalhome initiatives expanded in 2009-2013: providers, patients, andpayment incentives increased. Health Aff. 2014;33(10):1823-31.

15. Bitton A, Martin C, Landon BE. A nationwide survey of patient centeredmedical home demonstration projects. J Gen Intern Med. 2010;25(6):584-92.

16. Miles MB, Huberman AM. Qualitative data analysis: An expandedsourcebook, 2nd ed. Thousand Oaks, CA: SAGE Publications, Inc.;1994:213-219.

17. Summary results of this survey are available in our final evaluationreport—see Table 3–6 in Nichols D, Haber S, Romaire M, et al.Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP)Demonstration: Final Report. Baltimore: CMS; 2017 June. Available at:https://downloads.cms.gov/files/cmmi/mapcp-finalevalrpt.pdf.Accessed December 13, 2017. Our provider survey is included in theappendix to our final evaluation report—see Appendix U, in Nichols D,Haber S, Romaire M, et al. Evaluation of the Multi-Payer AdvancedPrimary Care Practice (MAPCP) Demonstration: Final Report-Appendices.Baltimore: CMS; 2017 June. Available at: https://downloads.cms.gov/files/cmmi/mapcp-finalevalrpt-appendix.pdf. Accessed December 13,2017.

18. CMS. Comprehensive Primary Care Plus (CPC+) Round 2 Payer Solicita-tion. Available at: https://innovation.cms.gov/Files/fact-sheet/cpcplus-payer-factsheet.pdf. Accessed December 13, 2017.

19. Wirth B, Takach M. State strategies to avoid antitrust concerns inmultipayer medical home initiatives. New York: Commonwealth Fund;2013. Available at: http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2013/jul/1694_wirth_state_strategies_avoid_antitrust_ib.pdf. Accessed December 13, 2017.

20. CMS. State Innovation Models Initiative: General Information. Availableat: https://innovation.cms.gov/initiatives/state-innovations/. AccessedDecember 13, 2017.

21. Brooks M. Most US Physicians Still Work in Small Practices. MedscapeMedical News. 2015. Available at: https://www.medscape.com/viewarticle/847833. Accessed December 13, 2017.


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http://dx.doi.org/https://downloads.cms.gov/files/cmmi/mapcp-finalevalrpt.pdf





http://dx.doi.org/https://innovation.cms.gov/Files/fact-sheet/cpcplus-payer-factsheet.pdf

http://dx.doi.org/https://innovation.cms.gov/Files/fact-sheet/cpcplus-payer-factsheet.pdf

http://dx.doi.org/http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2013/jul/1694_wirth_state_strategies_avoid_antitrust_ib.pdf



http://dx.doi.org/https://innovation.cms.gov/initiatives/state-innovations/

http://dx.doi.org/https://www.medscape.com/viewarticle/847833

http://dx.doi.org/https://www.medscape.com/viewarticle/847833

Offsetting Patient-Centered Medical Homes Investment Costs Through Per-Member-Per-Month or Medicare Merit-based Incentive Payment System Incentive Paymentsda Graca, Briget JD, MS; Ogola, Gerald O. PhD, MPH; Fullerton, Cliff MD, MS; McCorkle, Russell MBA; Fleming, Neil S. PhD

The Journal of Ambulatory Care Management: April/June 2018 - Volume 41 - Issue 2 - p 105–113doi: 10.1097/JAC.0000000000000224Original Articles

Primary care practices become patient-centered medical homes (PCMHs) to improve care. However, investment costs and opportunities to offset those costs are critical to the decision. We examined potential offsets through commercial payer per-member-per-month (PMPM) payments and the Medicare Merit-based Incentive Payment System (MIPS) for a network that spent $4 818 260 over 4 years obtaining and renewing PCMH recognition for 57 practices. With PMPM payments of $3.37 to $8.98, “breakeven” requires that 2.4% to 6.4% of the network's 1645 commercially insured patients per physician be covered, while applying MIPS incentive payments of half the maximum available each year to the network's average 2016 Medicare reimbursement of $196 812 per physician showed they would exceed PCMH costs by 2022.

Center for Clinical Effectiveness (Ms da Graca and Drs Ogola and Fleming), Baylor Scott & White Health, Dallas, Texas (Dr Fullerton); Robbins Institute for Health Policy & Leadership, Baylor University, Waco, Texas (Ms da Graca and Dr Fleming); Baylor Scott & White Quality Alliance, Dallas, Texas (Dr Fullerton); and HealthTexas Provider Network, Dallas, Texas (Mr McCorkle).

Correspondence: Briget da Graca, JD, MS, Center for Clinical Effectiveness, Baylor Scott & White Health, 8080 North Central Expressway, Ste 500, Dallas, TX 75206 ([email protected]).

This work was presented at the AcademyHealth National Policy Conference in Washington, District of Columbia, in January 2017.

This project was funded by the Agency for Healthcare Research and Quality, grant number R03 HS022621-01 (Principal Investigator: Neil S. Fleming).

The authors have no conflicts of interest to declare.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

Abstract Author Information

Page 1 of 2Offsetting Patient-Centered Medical Homes Investment Costs T... : The Journal of Ambulatory Care Management

4/25/2018https://journals.lww.com/ambulatorycaremanagement/Abstract/2018/04000/Offsetting_Patient_Centered_Medical_Homes.8.aspx

Patient-Centered Medical Home (PCMH) 2017:

Suggested Pathway The table below provides a suggested pathway for what practices might demonstrate for each check-in. A

practice does not have to follow this pathway. This table was developed to provide direction and a to practices for

how to approach the concepts and criteria.

To achieve recognition, practices must:

1. Meet all 40 core criteria and

2. Earn 25 credits in elective criteria across 5 of 6 concepts.

Multi-sites: Shared and Site-Specific Evidence

Some evidence can be shared (such as documented processes and demonstration of capability) and may be

submitted once for all sites or site groups. Other evidence (such as evidence of implementation, examples, reports,

Record Review Workbooks and Quality Improvement Workbooks) must be site-specific. Site -specific data may

be combined and submitted once on behalf of all sites or site groups. Some criteria require a combination of

shared and site-specific evidence, which is indicated as partially shared in the tables below. For multi-site groups,

it is suggested that the group demonstrate their shared criteria during their 1st check-in and then all of their site-

specific evidence for all of their sites at the subsequent check-ins.

= Evidence sharable across practice sites

** = Evidence that can be partially shared

Core Electives

1 Credit 2 Credits 3 Credits

Total Criteria

(100 criteria) 40 criteria 39 criteria 20 criteria 1 criterion

TEAM-BASED CARE AND PRACTICE ORGANIZATION (TC)

Competency A: The practice is committed to transforming the

practice into a sustainable medical home. Members of the care

team serve specific roles as defined by the practice’s

organizational structure and are equipped with the knowledge and

training necessary to perform those functions.

Check-in 1 Check-in 2 Check-in 3

TC 01*

(Core)

PCMH

Transformation

Leads

Designates a clinician lead of

the medical home and a staff

person to manage the PCMH

transformation and medical

home activities.

TC 02

(Core)

Structure & Staff

Responsibilities

Defines practice organizational

structure and staff

responsibilities/ skills to support

key PCMH functions.


New Single Site Suggested Pathway

Page 2 of 20


TC 03*

(1 Credit)

External PCMH

Collaborations

The practice is involved in

external PCMH-oriented

collaborative activities (e.g.,

federal/state initiatives, health

information exchanges).

TC 04 *

(2 Credits)

Patient/Family/Ca

regiver

Involvement in

Governance

Patients/families/caregivers are

involved in the practice’s

governance structure or on

stakeholder committees.

TC 05

(2 Credits)

Certified EHR

System

The practice uses an EHR

system (or modules) that has

been certified and issued an

ONC Certification ID, conducts

a security risk analysis and

implements security updates as

necessary correcting identified

security deficiencies.

Competency B: Communication among staff is organized to

ensure that patient care is coordinated, safe and effective. Check-in 1 Check-in 2 Check-in 3

TC 06

(Core)

**

Individual Patient

Care

Meetings/Commu

nication

Has regular patient care team

meetings or a structured

communication process focused

on individual patient care.

TC 07

(Core)

Staff Involvement

in Quality

Improvement

Involves care team staff in the

practice’s performance

evaluation and quality

improvement activities.

TC 08*

(2 Credits)

Behavioral Health

Care Manager

Has at least one care manager

qualified to identify and

coordinate behavioral health

needs.

Competency C: The practice communicates and engages patients

on expectations and their role in the medical home model of care. Check-in 1 Check-in 2 Check-in 3

TC 09

(Core)

Medical Home

Information

Has a process for informing

patients/ families/caregivers

about the role of the medical

home and provides patients/

families/caregivers with

materials that contain the

information.

Core Review: 2 criteria

Core Attestation: 3 criteria

1 Credit Review: 0 criteria

1 Credit Attestation: 1 criteria


2 Credit Attestation: 1



Page 3 of 20


criteria

* New criteria in PCMH 2017.



Page 4 of 20

KNOWING AND MANAGING YOUR PATIENTS (KM)

Competency A: Practice routinely collects comprehensive data

on patients to understand background and health risks of patients.

Practice uses information on the population to implement needed

interventions, tools and supports for the practice as a whole and

for specific individuals.

Check-in 1 Check-in

2 Check-in 3

KM 01

(Core)

Problem Lists Documents an up-to-date

problem list for each patient

with current and active

diagnoses.

KM 02

(Core)

*F. and G.

are new

**

Comprehensive

Health Assessment

Comprehensive health

assessment includes (all items

required):

A. Medical history of patient

and family

B. Mental health/substance

use history of patient and

family

C. Family/social/cultural

characteristics

D. Communication needs.

E. Behaviors affecting health

F. Social functioning*

G. Social Determinants of

Health*

H. Developmental screening

using a standardized tool.

(NA for practices with no

pediatric population under

30 months of age.)

I. Advance care planning.

(NA for pediatric

practices)

KM 03

(Core)

**

Depression

Screening

Conducts depression

screenings for adults and

adolescents using a

standardized tool.

KM 04*

(1 Credit)

**

Behavioral Health

Screenings

Conducts behavioral health

screenings and/or assessments

using a standardized tool.

(implement two or more)

A. Anxiety.

B. Alcohol use disorder.



Page 5 of 20


C. Substance use disorder.

D. Pediatric behavioral health

screening.

E. Post-traumatic stress

disorder.

F. ADHD.

G. Postpartum depression.

KM 05*

(1 Credit)

**

Oral Health

Assessment &

Services

Assesses oral health needs

and provides necessary

services during the care visit

based on evidence-based

guidelines or coordinates with

oral health partners.

KM 06

(1 Credit)

Predominant

Conditions &

Concerns

Identifies the predominant

conditions and health

concerns of the patient

population.

KM 07*

(2 Credits)

Social

Determinants of

Health

Understands social

determinants of health for

patients, monitors at the

population level and

implements care interventions

based on these data.

KM 08*

(1 Credit)

Patient Materials Evaluates patient population

demographics/communication

preferences/health literacy to

tailor development and

distribution of patient

materials.

Competency B: The practice seeks to meet the needs of a diverse

patient population by understanding the population’s unique

characteristics and language needs. The practice uses this

information to ensure linguistic and other patient needs are met.

Check-in 1 Check-in

2 Check-in 3

KM 09

(Core)

Diversity Assesses the diversity (race,

ethnicity and one other aspect

of diversity) of its population.

KM 10

(Core)

Language Assesses the language needs

of its population.

KM 11

(1 Credit)

*A. and C.

Population Needs Identifies and addresses

population-level needs based

on the diversity of the

practice and the community



Page 6 of 20


are new

(demonstrate at least 2):

A. Target population health

management on

disparities in care.*

B. Address health literacy of

the practice.

C. Educate practice staff in

cultural competence.*

Competency C: The practice proactively addresses the care

needs of the patient population to ensure needs are met. Check-in 1

Check-in

2 Check-in 3

KM 12

(Core)

Proactive

Reminders

Proactively and routinely

identifies populations of

patients and reminds them, or

their families/caregivers

about needed services (must

report at least 3 categories):

A. Preventive care services.

B. Immunizations.

C. Chronic or acute care

services.

D. Patients not recently seen

by the practice.

KM 13*

(2 Credits)

Excellence in

Performance

Demonstrates excellence in a

benchmarked/performance-

based recognition program

assessed using evidence-

based care guidelines.

[Specifics yet to be defined

but at minimum includes

DRP/HSRP recognition by

NCQA.]

Competency D: The practice addresses medication safety and

adherence by providing information to the patient and

establishing processes for medication documentation,

reconciliation and assessment of barriers.

Check-in 1 Check-in

2 Check-in 3

KM 14

(Core)

Medication

Reconciliation

Reviews and reconciles

medications for more than 80

percent of patients received

from care transitions.

KM 15

(Core)

Medication Lists Maintains an up-to-date list of

medications for more than 80

percent of patients.



Page 7 of 20


KM 16

(1 Credit)

New Prescription

Education

Assesses understanding and

provides education, as

needed, on new prescriptions

for more than 50 percent of

patients/families/ caregivers.

KM 17

(1 Credit)

Medication

Responses &

Barriers

Assesses and addresses

patient response to

medications and barriers to

adherence for more than 50

percent of patients, and dates

the assessment.

KM 18*

(1 Credit)

Controlled

Substance

Database Review

Reviews controlled substance

database when prescribing

relevant medications.

KM 19*

(2 Credits)

Prescription Claims

Data

Systematically obtains

prescription claims data in

order to assess and address

medication adherence.

Competency E: The practice incorporates evidence-based

clinical decision support across a variety of conditions to

ensure effective and efficient care is provided to patients. Check-in 1

Check-in

2 Check-in 3

KM 20

(Core)

Clinical Decision

Support

Implements clinical decision

support following evidence-

based guidelines for care of

(must demonstrate at least 4

criteria):

A. Mental health condition.

B. Substance use disorder.

C. A chronic medical

condition.

D. An acute condition.

E. A condition related to

unhealthy behaviors.

F. Well child or adult care.

G. Overuse/appropriateness

issues.

Competency F: The practice identifies/considers and

establishes connections to community resources to collaborate

and direct patients to needed support. Check-in 1

Check-in

2 Check-in 3

KM 21*

(Core)

Community

Resource Needs

Uses information on the

population served by the

practice to prioritize needed



Page 8 of 20


community resources.

KM 22

(1 Credit)

Access to

Educational

Resources

Provides access to

educational resources, such

as materials, peer-support

sessions, group classes,

online self-management tools

or programs.

KM 23*

(1 Credit)

Oral Health

Education

Provides oral health

education resources to

patients.

KM 24

(1 Credit)

Shared Decision-

Making Aids

Adopts shared decision-

making aids for preference-

sensitive conditions.

KM 25*

(1 Credit)

School/Intervention

Agency

Engagement

Engages with schools or

intervention agencies in the

community.

KM 26

(1 Credit)

Community

Resource List

Routinely maintains a current

community resource list

based on the needs identified

in Core KM 21.

KM 27

(1 Credit)

Community

Resource

Assessment

Assesses the usefulness of

identified community support

resources.

KM 28*

(2 Credits)

Case Conferences Has regular “case

conferences” involving

parties outside the practice

team (e.g., community

supports, specialists).





criteria



criteria




Page 9 of 20

PATIENT-CENTERED ACCESS AND CONTINUITY (AC)

Competency A: The practice seeks to enhance access by

providing appointments and clinical advice based on patients’

needs. Check-in 1 Check-in 2 Check-in 3

AC 01*

(Core)

**

Access Needs &

Preferences

Assesses the access needs and

preferences of the patient

population.

AC 02

(Core)

**

Same-Day

Appointments

Provides same-day

appointments for routine and

urgent care to meet identified

patients’ needs.

AC 03

(Core)

Appointments

Outside

Business Hours

Provides routine and urgent

appointments outside regular

business hours to meet

identified patient needs.

AC 04

(Core)

Timely Clinical

Advice by

Telephone

Provides timely clinical

advice by telephone.

AC 05

(Core)

**

Clinical Advice

Documentation

Documents clinical advice in

patient records and confirms

clinical advice and care

provided after-hours does not

conflict with patient medical

record.

AC 06

(1 Credit)

**

Alternative

Appointments

Provides scheduled routine or

urgent appointments by

telephone or other technology

supported mechanisms.

AC 07

(1 Credit)

Electronic

Patient Requests

Has a secure electronic system

for patients to request

appointments, prescription

refills, referrals and test

results.

AC 08

(1 Credit)

Two-Way

Electronic

Communication

Has a secure electronic system

for two-way communication

to provide timely clinical

advice.

AC 09*

(1 Credit)

Equity of Access Uses information on the

population served by the

practice to assess equity of

access that considers health

disparities.



Page 10 of 20

Competency B: Practices support continuity through

empanelment and systematic access to the patient’s medical

record. Check-in 1 Check-in 2 Check-in 3

AC 10

(Core)

Personal

Clinician

Selection

Helps

patients/families/caregivers

select or change a personal

clinician.

AC 11

(Core)

Patient Visits

with

Clinician/Team

Sets goals and monitors the

percentage of patient visits

with selected clinician or

team.

AC 12

(2 Credits)

Continuity of

Medical Record

Information

Provides continuity of medical

record information for care

and advice when the office is

closed.

AC 13*

(1 Credit)

**

Panel Size

Review &

Management

Reviews and actively

manages panel sizes.

AC 14*

(1 Credit)

**

External Panel

Review &

Reconciliation

Reviews and reconciles panel

based on health plan or other

outside patient assignments.





criteria



criteria




Page 11 of 20

CARE MANAGEMENT AND SUPPORT (CM)

Competency A: The practice systematically identifies patients that

would benefit most from care management. Check-in 1 Check-in 2 Check-in 3

CM 01

(Core)

Identifying

Patients for

Care

Management

Considers the following when

establishing a systematic process and

criteria for identifying patients who

may benefit from care management

(practice must include at least 3 in its

criteria):

A. Behavioral health conditions

B. High cost/high utilization

C. Poorly controlled or complex

conditions

D. Social determinants of health

E. Referrals by outside

organizations (e.g., insurers,

health system, ACO), practice

staff or patient/family/ caregiver

CM 02

(Core)

Monitoring

Patients for

Care

Management

Monitors the percentage of the total

patient population identified through

its process and criteria.

CM 03*

(2 Credits)

Comprehensive

Risk-

Stratification

Process

Applies a comprehensive risk-

stratification process to entire patient

panel in order to identify and direct

resources appropriately.

Competency B: For patients identified for care management, the

practice consistently uses patient information and collaborates with

patients/families/ caregivers to develop a care plan that addresses

barriers and incorporates patient preferences and lifestyle goals

documented in the patient’s chart.


CM 04

(Core)

Person-

Centered Care

Plans

Establishes a person-centered care

plan for patients identified for care

management.

CM 05

(Core)

Written Care

Plans

Provides written care plan to the

patient/family/caregiver for patients

identified for care management.

CM 06

(1 Credit)

Patient

Preferences &

Goals

Documents patient preference and

functional/lifestyle goals in

individual care plans.



Page 12 of 20


CM 07

(1 Credit)

Patient Barriers

to Goals

Identifies and discusses potential

barriers to meeting goals in


CM 08

(1 Credit)

Self-

Management

Plans

Includes a self-management plan in


CM 09*

(1 Credit)

Care Plan

Integration

Care plan is integrated and

accessible across settings of care.



1 Credit Review: 1 criterion




criteria

* New criteria in PCMH 2017



Page 13 of 20

CARE COORDINATION AND CARE TRANSITIONS (CC)

Competency A: The practice effectively tracks and manages

laboratory and imaging tests important for patient care and

informs patients of the result. Check-in 1 Check-in 2

CC 01

(Core)

**

Lab & Imaging

Test

Management

The practice systematically

manages lab and imaging

tests by:

A. Tracking lab tests until

results are available,

flagging and following up

on overdue results.

B. Tracking imaging tests

until results are available,

flagging and following up

on overdue results.

C. Flagging abnormal lab

results, bringing them to

the attention of the

clinician.

D. Flagging abnormal

imaging results, bringing

them to the attention of

the clinician.

E. Notifying

patients/families/

caregivers of normal lab

and imaging test results.

F. Notifying

patients/families/

caregivers of abnormal

lab and imaging test

results.

CC 02

(1 Credit)

**

Newborn

Screenings

Follows up with the inpatient

facility about newborn

hearing and newborn blood-

spot screening.

CC 03*

(2 Credits)

Appropriate Use

for Labs &

Imaging

Uses clinical protocols to

determine when imaging and

lab tests are necessary.

Competency B: The practice provides important information

in referrals to specialists and tracks referrals until the report is

received.

Shared or

Site-

Specific?

Review or

Attestation?



Page 14 of 20


CC 04

(Core)

**

Referral

Management

The practice systematically

manages referrals by:

A. Giving the consultant or

specialist the clinical

question, the required

timing and the type of

referral

B. Giving the consultant or

specialist pertinent

demographic and clinical

data, including test

results and the current

care plan

C. Tracking referrals until

the consultant or

specialist’s report is

available, flagging and

following up on overdue

reports

CC 05*

(2 Credits)

Appropriate

Referrals

Uses clinical protocols to

determine when a referral to

a specialist is necessary.

CC 06*

(1 Credit)

Commonly

Used Specialists

Identification

Identifies the

specialists/specialty types

most commonly used by the

practice.

CC 07

(2 Credits)

Performance

Information for

Specialist

Referrals

Considers available

performance information on

consultants/ specialists when

making referrals.

CC 08

(1 Credit)

Specialist

Referral

Expectations

Works with nonbehavioral

healthcare specialists to

whom the practice

frequently refers to set

expectations for information

sharing and patient care.

CC 09

(2 Credits)

Behavioral

Health Referral

Expectations

Works with behavioral

healthcare providers to

whom the practice

frequently refers to set

expectations for information

sharing and patient care.



Page 15 of 20


CC 10

(2 Credits)

**

Behavioral

Health

Integration

Integrates behavioral

healthcare providers into the

care delivery system of the

practice site.

CC 11

(1 Credit)

**

Referral

Monitoring

Monitors the timeliness and

quality of the referral

response.

CC 12

(1 Credit)

Co-

Management

Arrangements

Documents co-management

arrangements in the patient’s

medical record.

CC 13*

(2

Credits)

**

Treatment

Options & Costs

Engages with patients

regarding cost implications

of treatment options.

Competency C: The practice connects with other health care

facilities to support patient safety throughout care transitions.

The practice receives and shares necessary patient treatment

information to coordinate comprehensive patient care.


CC 14

(Core)

**

Identifying

Unplanned

Hospital & ED

Visits

Systematically identifies

patients with unplanned

hospital admissions and

emergency department

visits.

CC 15

(Core)

**

Sharing Clinical

Information

Shares clinical information

with admitting hospitals and

emergency departments.

CC 16

(Core)

**

Post-

Hospital/ED

Visit Follow-Up

Contacts

patients/families/caregivers

for follow-up care, if

needed, within an

appropriate period following

a hospital admission or

emergency department visit.

CC 17*

(1 Credit)

**

Acute Care

After Hours

Coordination

Systematic ability to

coordinate with acute care

settings after hours through

access to current patient

information.

CC 18

(1 Credit)

**

Information

Exchange

during

Exchanges patient

information with the hospital

during a patient’s



Page 16 of 20


Hospitalization hospitalization.

CC 19

(1 Credit)

**

Patient

Discharge

Summaries

Implements process to

consistently obtain patient

discharge summaries from

the hospital and other

facilities.

CC 20

(1 Credit)

Care Plan

Collaboration

for Practice

Transitions

Collaborates with the

patient/ family/caregiver to

develop/ implement a

written care plan for

complex patients

transferring into/out of the

practice (e.g., from pediatric

care to adult care).

CC 21

(Maximum

3 Credits)

External

Electronic

Exchange of

Information

Demonstrates electronic

exchange of information

with external entities,

agencies and registries (may

select 1 or more):

A. Regional health

information organization

or other health

information exchange

source that enhances the

practice’s ability to

manage complex patients.

(1 Credit)

B. Immunization registries

or immunization

information systems. (1

Credit)

C. Summary of care record

to another provider or

care facility for care

transitions. (1 Credit)

Core Review: 2

criteria


1 Credit Review:

2 criteria

1 Credit

Attestation: 7 criteria

2 Credit Review:

5 criteria

2 Credit

Attestation: 1 criterion

3 Credit Attestation:

1 criterion




Page 17 of 20

PERFORMANCE MEASUREMENT AND QUALITY IMPROVEMENT (QI)

Competency A: The practice measures to understand current

performance and to identify opportunities for improvement. Check-in 1 Check-in 2 Check-in 3

QI 01

(Core)

*D. is New

Clinical Quality

Measures

Monitors at least five

clinical quality

measures across the

four categories (must

monitor at least 1

measure of each type):

A. Immunization

measures.

B. Other preventive care

measures.


clinical measures.

D. Behavioral health

measures.*

QI 02

(Core)

Resource Stewardship

Measures

Monitors at least two

measures of resource

stewardship (must

monitor at least 1

measure of each type):

A. Measures related to

care coordination.

B. Measures affecting

health care costs.

QI 03

(Core)

**

Appointment

Availability Assessment

Assesses performance on

availability of major

appointment types to meet

patient needs and

preferences for access.

QI 04

(Core)

Patient Experience

Feedback

Monitors patient

experience through:

A. Quantitative data:

Conducts a survey

(using any instrument)

to evaluate

patient/family/

caregiver experiences

across at least three

dimensions, such as:

Access.

Communication.

Coordination.

Whole person care,



Page 18 of 20


self-management

support and

comprehensiveness.

B. Qualitative data:

Obtains feedback from

patients/

families/caregivers

through qualitative

means

QI 05

(1 Credit)

Health Disparities

Assessment

Assesses health disparities

using performance data

stratified for vulnerable

populations. (must choose

one from each section):

A. Clinical quality

B. Patient experience

QI 06

(1 Credit)

Validated Patient

Experience Survey Use

The practice uses a

standardized, validated

patient experience survey

tool with benchmarking

data available.

QI 07

(2 Credits)

Vulnerable Patient

Feedback

The practice obtains

feedback on experiences

of vulnerable patient

groups.

Competency B: The practice evaluates its performance against

goals or benchmarks and uses the results to prioritize and

implement improvement strategies. Check-in 1 Check-in 2 Check-in 3

QI 08

(Core)

*D. is New

Goals & Actions to

Improve Clinical Quality

Measures

Sets goals and acts to

improve upon at least

three measures across at

least three of the four

categories:

A. Immunization

measures.

B. Other preventive care

measures.


clinical measures.

D. Behavioral health

measures.*



Page 19 of 20


QI 09

(Core)

Goals & Actions to

Improve Resource

Stewardship Measures


improve upon at least one

measure of resource

stewardship:

A. Measures related to

care coordination.

B. Measures affecting

health care costs.

QI 10

(Core)

Goals & Actions to

Improve Appointment

Availability


improve on availability of

major appointment types

to meet patient needs and

preferences.

QI 11

(Core)

Goals & Actions to

Improve Patient

Experience


improve on at least 1

patient experience

measure.

QI 12

(2 Credits)

Improved Performance Achieves improved

performance on at least 2

performance measures.

QI 13

(1 Credit)

Goals & Actions to

Improve Disparities in

Care/Service


improve disparities in

care or services on at least

1 measure.

QI 14

(2 Credits)

Improved Performance

for Disparities in Care/

Service

Achieves improved

performance on at least 1

measure of disparities in

care or service.

Competency C: The practice is accountable for performance. The

practice shares performance data with the practice, patients and/or

publicly for the measures and patient populations identified in the

previous section.


QI 15

(Core)

**

Reporting Performance

within the Practice

Reports practice-level or

individual clinician

performance results

within the practice for

measures reported by the

practice.

QI 16

(1 Credit)

**


Publicly or with Patients

Reports practice-level or

individual clinician

performance results

publicly or with patients

for measures reported by



Page 20 of 20


the practice.

QI 17

(2 Credits)

Patient/Family/Caregiver

Involvement in Quality

Improvement

Involves

patient/family/caregiver

in quality improvement

activities.

QI 18

(2 Credits)


Measures to

Medicare/Medicaid

Reports clinical quality

measures to Medicare or

Medicaid agency.

QI 19*

(Maximum

2 credits)

Value-Based Contract

Agreements

Up-Side Risk Contract

Two-Sided Risk

Contract

Is engaged in Value-

Based Contract

Agreement. (Maximum 2

credits)

A. Practice engages in

up-side risk contract (1

credit)

B. Practice engages in

two-sided risk contract

(2 credits)





2 Credit Review: 2

criteria


criteria


Annual Reporting Requirements for PCMH Recognition Overview & Table Reporting Period: 4/3/2017–9/30/2018

Redesign Goals

NCQA redesigned its PCMH Recognition program in April 2017 for practices to maintain an ongoing

status as a recognized practice with annual reporting, replacing the current program’s three-year

recognition cycle. The redesigned program offers:

• Flexibility. Practices take the path to recognition that suits their strengths, schedule and goals.

• Personalized service. Practices get more interaction with NCQA. Each practice is assigned a

NCQA Representative who’ll serve as the primary NCQA contact and “go-to” guide.

• User-friendly approach. Reporting requirements remain meaningful, but with simplified

reporting and less paperwork.

• Continuous improvement. Annual checks help practices strengthen as medical homes by

frequently reviewing progress and encouraging performance improvement.

• Alignment with changes in health care. The program aligns with current public and private

initiatives and can adapt to future changes.

The recognition process has three parts:

1. Commit. When a practice signs up to work with NCQA, they complete an assessment online.

The practice receives guidance from their NCQA Representative to determine their evaluation

plan and schedule.

2. Transform. Practices gradually transform, building upon their prior success. During this time,

they demonstrate progress by submitting data and evidence to be evaluated by NCQA. Practices

submit through a newly streamlined system designed to reduce paperwork and administrative

hassles.

Along the way, NCQA conducts virtual reviews—check-ins—with the practice to gauge progress

and to discuss next steps in the evaluation. The virtual reviews—conducted via screen sharing

technology—give practices immediate and personalized feedback on what is going well and

what needs to improve. This makes NCQA evaluations more educational and collaborative.

3. Succeed. The practice continues to implement and enhance their PCMH model to meet the

needs of patients. Each year, the practice checks in with NCQA to demonstrate ongoing

activities consistent with the PCMH model and the implementation of PCMH standards. This

reporting includes attesting to certain policies and procedures and submission of key data.

Q-PASS - New Online Platform

NCQA launched Q-PASS, a new online platform, to support the new recognition process, in April 2017.

Practices can apply for recognition, sign agreements, access training and other resources, submit

evidence, update and confirm data, track evaluations completed, print certificates and sustain their

recognition using this system.

Updated September 22, 2017 Page 2 of 20

Sustaining Your Recognition

This document focuses on data reporting requirements for the annual reporting. Practices will

demonstrate they continue to align with recognition requirements by submitting data and evidence on

these critical aspects of PCMH:

• Patient-centered access.

• Team-based care.

• Population health management.

• Care management.

• Care coordination and care transitions.

• Performance measurement and quality

improvement.

Practices will also have the opportunity to submit data and evidence on special topics, such as

behavioral health.

Annual Reporting Process: Reporting, Audit and Decision

• Practices will use Q-PASS to submit data and evidence for their annual reporting.

• Practices must verify core features of the medical home have been sustained.

• Practices must meet the minimum number of requirements for each category.

• NCQA reviews submission and notifies practices of their sustained recognition status.

• NCQA will randomly select practices for audit to validate attestation and submission.

• Practices that do not submit on time or fail to meet other requirements may have their

recognition status suspended or revoked. That may include having their recognition status

changed to “Not Recognized.”

Annual Reporting Requirements (Annual Attestation and Reporting Requirements)

In this version, practices will attest that they have continued to adopt the medical home principles and

maintained their medical home recognition using the PCMH Annual Questionnaire in Q-PASS. In the

future, practices will attest to criteria based on the current PCMH program, which consists of key

expectations that recognized practices must meet as a medical home. In addition to this attestation, the

PCMH Annual Reporting Requirements table (starting on page 3 of this document) outlines reporting

options for eligible recognized practices through successful transformation and achievement of PCMH

recognition.

Annual reporting requirements may be removed, modified or added over time. Practices will be notified

of changes and given time to prepare data and evidence.

Electronic Clinical Quality Measures

Electronic Clinical Quality Measures (eCQMs) are standardized performance measures from electronic

health records (EHR) or health information technology systems. In the future, practices will have the

option to submit electronic clinical quality measures (eCQMs) to NCQA in support of their recognition

process. The identified measures can be submitted through electronic health record systems, health

information exchanges, qualified clinical data registries (QCDRs) and data analytics companies as long

as they can use the electronic specifications as defined by the Centers for Medicare & Medicaid

Services for the ambulatory quality reporting programs. More details about the data submission process

to NCQA will be forthcoming.

Shared vs. Site-Specific Evidence

If evidence is identified as “shared,” the organization may submit it once on behalf of all or a specified

group of practice sites. If evidence is identified as “site-specific,” the practice must provide site specific

http://www.ncqa.org/portals/0/Programs/Recognition/PCMH/Quality_Measures_Crosswalk.pdf

Page 3 of 20 Updated September 22, 2017

data or evidence. The organization should go to the Share Credits tab from their Organization

Dashboard in Q-PASS to set up their shared site groups.


Patient-Centered Access (AR-PA)

Has your practice continued to monitor appointment access?

Choose 1 option from the 3 below to submit for your annual reporting.

Required (R) or Optional (O)

Requirement

O

AR-PA1 Patient Experience Feedback – Access

If your patient experience survey includes questions related to access, provide the following:

1. Patient Experience – Survey Tool (Shared)

• Upload copy of the patient experience survey tool. Practices that use a CAHPS survey do not need to provide the survey.

• Indicate whether practice utilizes the CAHPS survey tool.

2. Patient Experience – Data (Site-specific)

Enter:

• Numerator: Number of completed surveys in the past 12 months.

• Denominator: Number of patients surveyed in the past 12 months.

• Reporting period.

3. Patient Experience – Report (Shared, if report is stratified by site.)

Upload report with results from the access questions.

O

AR-PA2 Third Next Available Appointment

1. Third Next Available Appointment – Urgent (Site-specific)

Enter the third next available appointment for urgent appointments.

2. Third Next Available Appointment – Routine (Site-specific)

Enter the third next available appointment for routine appointments (new patient physical, routine exam, return visit exam). For routine requests, exclude any appointments blocked for same-day or urgent visits (since they are “blocked off” the schedule).

Practices may use the Institute for Healthcare Improvement’s (IHI) method to calculate the third next available appointment.

• Sample all clinicians on the team once a week, on the same day, at the same time of day, for at least one month during the annual reporting.

• Count the number of days between a request for an appointment (e.g., enter dummy patient) with a physician and the third next available appointment for a new patient physical, routine exam, or return visit exam.

• Report the average number of days for all physicians sampled.



Requirement

Note: Count calendar days (e.g. include weekends) and days off.

O

AR-PA3 Monitoring Access – Other Method

1. Other Method (Site-specific) Upload evidence that demonstrates a different method used for enhanced patient scheduling/same-day service.

Examples may include:

• A report showing monitoring of access to both urgent and routine (new patient physical, routine exam, return visit exam) appointments using a method other than option 2. The method must exclude use of appointment times from cancellations and no-shows and demonstrate a minimum of 5 consecutive days.

• A summary or report of appointments designated for same-day urgent and routine visits.

Note: Adding ad hoc or unscheduled appointments to a full day of scheduled appointments does not meet the requirement. Conducting a walk-in clinic or open access scheduling does not meet the requirement. There should be appointments available to allow for patient planning needs.


Team-Based Care (AR-TC) Has your practice continued to use a team-based approach to provide primary care?

Choose 1 option from the 2 below to submit for your annual reporting.


Requirement

O

AC-TC1 Pre-Visit Planning Activities

1. Pre-Visit Planning Activities (Shared) Does your practice anticipate and plan for upcoming visits? Check all that apply.

☐ Team meetings/huddles.

☐ Structured communication.

☐ Dashboard in the EHR.

☐ Checklist.

☐ Appointment notes.

☐ Other __________________

O

AC-TC2 Employee Experience Feedback

If your employee experience/satisfaction survey covers, at a minimum, collaboration, communication and team dynamics, provide the following:

1. Employee Experience – Survey Tool (Shared)

Upload copy of the employee experience survey tool.

2. Employee Experience – Data (Shared, at least 1 employee from each site must be included)

Enter:

• Numerator: Number of employees (staff/clinicians) who completed the survey in the past 12 months.

• Denominator: Number of employees (staff/clinicians) surveyed in the past 12 months.


3. Employee Experience – Report (Shared, report does not need to be stratified by site)

Upload report of results for all questions related to collaboration, communication, team dynamics.


Population Health Management (AR-PH)

Has your practice continued to proactively remind patients of upcoming services?

Submit the information requested for your annual reporting.


Requirement

R

AR-PH1 Proactive Reminders

1. Proactive Reminders - Number of Services (Shared) Does your practice send proactive reminders for a minimum of 5 different services across at least 2 of the following categories: Preventive care services, Immunizations, Chronic or acute care services, Patients not seen regularly, Patients who need medication monitoring or alerts?

• Yes • No

2. Proactive Reminders – Frequency (Shared)

For each category listed above, identify how frequently your practice generate lists and reminders to patients.

• Monthly

• Quarterly

• Annually

• Other _____________

Note: If 75 percent of clinicians have DRP or HSRP recognition, practice receives credit for three chronic care services.


Care Management (AR-CM)

Has your practice continued to identify patients who may benefit from care management?

Submit the information requested for your annual reporting.


Requirement

R

AR-CM1 Identifying and Monitoring Patients for Care Management

1. Care Management Criteria (Shared)

Which of the following are considered in your practice's criteria for identifying patients who may benefit from care management? Must select at least two from the list below. Check all that apply.

☐ Behavioral health conditions.

☐ High cost/high utilization.

☐ Poorly controlled or complex conditions.

☐ Social determinants of health.

☐ Referrals by outside organizations, practice staff or patient/family/caregiver.

R 2. Care Management - Number of Patients Identified (Site-specific)

Enter the number of unique patients identified for care management using the criteria selected above.

Informational

3. Total Number of Patients (Optional data, Site-specific)

Enter the total number of unique patients in the practice.

4. Total Number of Patient Encounters (Optional data, Site-specific)

Enter the number of unique patients who have had an encounter with the practice in the past year.

5. Care Management - Number of Patient Encounters (Optional data, Site-specific)

Enter the number of unique patients identified for care management who have had an encounter with the practice in the past year.


Care Coordination and Care Transitions (AR-CC)

Has your practice continued to coordinate care with labs, specialists, institutional settings or other care facilities?

Respond to AR-CC1, then choose 1 additional option from the 4 below to submit for your annual reporting.

Required (R) or

Optional (O)

Requirement

Manual Option

R AR-CC1 Care Coordination Processes

Attest to referral tracking and follow-up, test tracking and follow-up and care transitions.

1. Tracking Lab Tests, Imaging Tests, Transitions of Care - Documented Process (Shared)

Does your practice use a continuous process for the following? Check all that apply. Tracking labs.

☐ Tracking lab tests

☐ Tracking imaging tests

☐ Transitions of care

2. Tracking, Flagging and Follow-up on Lab Tests (Shared)

Does your practice track labs until results are available, flagging and following up on overdue results?

• Yes

• No

3. Tracking, Flagging and Follow-up on Imaging Tests (Shared)

Does your practice track imaging tests until results are available, flagging and following up on overdue results?

• Yes

• No

4. Tracking, Flagging and Follow-up on Specialist Referrals (Shared)

Does your practice track referrals until specialist reports are available, flagging and following up on overdue reports?

No alternative reporting method available.


Required (R) or

Optional (O)

Requirement

Manual Option

• Yes

• No

O AR-CC2 Patient Experience Feedback – Care Coordination

If your patient experience survey includes questions related to care coordination, provide the following:

1. Patient Experience – Survey Tool (Shared)

• Upload Copy of the patient experience survey tool. Practices that use a CAHPS survey do not need to provide the survey.

• Indicate whether practice utilizes the CAHPS survey tool.

2. Patient Experience – Data (Site-specific)

Enter:

• Numerator: Number of completed surveys in the past 12 months.

• Denominator: Number of patients surveyed in the past 12 months.


3. Patient Experience – Report (Shared, if report is stratified by site)

Upload report with results from the care coordination questions.

No alternative reporting method available.

AR-CC3 Lab and Imaging Test Tracking

1. Tracking Lab Test Results – Data (Site-specific)

Enter:

• Numerator: Number of reports received from lab orders (count one report per order, with full results, even if reports for individual portions of an order come back at different times).

• Denominator: Number of lab orders sent in the prior 12 months.


IF USING MANUAL DATA (30 lab orders and 30 imaging orders)

1. Tracking Lab Test Results – Data (Site-specific)

Enter:

• Numerator: Number of lab reports received back from orders. Search the chart or tracking tool for the 30 lab orders and report how many had a lab report that came back to the practice from the lab order (one report per order, full results of all tests).


Required (R) or

Optional (O)

Requirement

Manual Option

2. Imaging Tracking Imaging Test Results – Data (Site-specific)

Enter:

• Numerator: Number of reports received from imaging orders (count one report per order, with full results, even if reports for individual portions of an order come back at different times).

• Denominator: Number of imaging orders sent in the prior 12 months.


• Denominator: 30. Pick 30 consecutive lab orders from the past year (within 12 months prior to the reporting date).


2. Imaging Tracking Imaging Test Results – Data (Site-specific)

Enter:

• Numerator: Number of reports received from imaging orders (count one report per order, with full results, even if reports for individual portions of an order come back at different times).

• Denominator: 30. Pick 30 consecutive imaging orders from the past year (within 12 months prior to the reporting date).


O AR-CC4 Referral Tracking

1. Tracking Referrals – Data (Site-specific)

Enter:

• Numerator: Number of referral orders with consultant reports received from specialists from the referral order list above (count one report per referral).

• Denominator: Number of referral orders sent to specialists.

• Reporting period. 2. Tracking Referrals - eCQMs (Shared)

Does your practice have the capability to submit CMS eCQM #50: Closing the referral loop: receipt of specialist report (using the QRDA format)?

• Yes

• No

IF USING MANUAL DATA

1. Tracking Referrals – Data (Site-specific)

Enter:

• Numerator: Number of consultant reports received back from requests. Search the chart or tracking tool for the 30 referrals and report how many have a consultant report that came back to the practice from the referral (one report per referral).

• Denominator: 30. Pick 30 consecutive referrals to specialists from the past year (within 12 months prior to the reporting date).



Required (R) or

Optional (O)

Requirement

Manual Option

O AR-CC5 Care Transitions

Track percentage of care transitions for which a summary of care document or discharge instructions have been received.

1. Care Transitions Follow-up - Data (Site-specific)

Enter:

• Numerator: Number of transitions in the denominator for which practice received discharge instructions or a summary of care document, including the following data, as applicable: transitioning provider contact information, procedures, encounter diagnosis, laboratory tests, vital signs, care plan goals and instructions, discharge instructions.

• Denominator: Number of patient transitions identified by the practice (transitioned by a facility, including hospitals, ERs, skilled nursing facilities and surgical centers) within the prior 12-month period.

Note: Facilities other than hospitalizations and ED visits may be excluded.


Note: This information is not required to be transmitted electronically.


1. Care Transitions Follow-up - Data (Site-specific)

Enter:

• Numerator: Number of summary care documents/discharge instructions. Search the chart or tracking tool for the 30 care transitions and report how many have discharge instructions or a summary of care document associated with them.

• Denominator: 30. Pick 30 consecutive care transitions from the past year (within 12 months prior to the reporting date).

Note: Facilities other than hospitalizations and ED visits may be excluded.



Performance Measurement and Quality Improvement (AR-QI)

Has your practice continued to collect and use performance measurement data for quality improvement activities?

Practices must submit the information requested for your annual reporting.

Required (R) or

Optional (O) Requirement

R

AR-QI1 Clinical Quality Measures

1. Quality Improvement Worksheet (Shared, some data must be site-specific)

Upload Quality Improvement (QI) Worksheet.

At least annually, the practice measures or receives data on at least five clinical quality measures across two of the following three categories:

• Immunizations.

• Other preventive care.

• Chronic/acute care.

Use the QI Worksheet to provide the following information for each measure:

A. The measure category. (Shared)

B. The measure name. (Shared)

C. The denominator description for the measure. (Shared)

D. The numerator description for the measure. (Shared)

E. The number of patients in the denominator (after exclusions). (Site-specific)

F. The number of patients in the numerator. (Site-specific)

G. Reporting period. (Site-specific)

H. Was the measure a target for quality improvement in the past year? (Yes/No).

Note: If your practice has an alternative report that is inclusive of all data required in the QI Worksheet (A-H), it may upload as evidence in lieu of the QI Worksheet.

2. Clinical Quality Measures - eCQMs (Shared)

Does your practice have the capability to submit at least three electronic measures (using the QRDA format) across at least two of the following categories: Immunizations, Other preventive care, or Chronic/acute care?

• Yes

• No

Note: Submission of eCQMs is currently under development.


Required (R) or


R

AR-QI2 Resource Stewardship Measures



At least annually, the practice measures or receives data on at least one resource stewardship/utilization/health care cost measure.











2. Resource Stewardship Measure - eCQMs (Shared)

Does your practice have the capability to submit at least one electronic measure (using the QRDA format) in the resource stewardship category?

• Yes

• No


R

AR-QI3 Patient Experience Feedback



At least annually, the practice measures or receives data on at least one patient experience measure.





Required (R) or









2. Patient Feedback - Other Method (Shared)

Upload other evidence demonstrating a patient advisory council or other method of patient feedback if not using the QI worksheet to demonstrate Patient Experience Feedback.


Special Topic: Behavioral Health (AR-BH)

Addressing the behavioral health needs of patients is an important aspect of comprehensive, whole-person care. In this section,

NCQA seeks simply to understand the models used by recognized practices.

Practices must submit the information about behavioral health based on the information outlined below but the responses will not impact

recognition status. This special topic section is to help move practices towards better integration of behavioral health and to help NCQA

track the degree to which practices are doing so in aggregate.

If your practice does not do any of the activities below, please select “This does not apply to us” in Q-PASS. This will alert NCQA that your

practice does not conduct a specific behavioral health service or activity.

Requirement

Informational

AR-BH1 Behavioral Health eCQMs

1. Behavioral Health Measure - eCQMs (Shared) Does your practice have the capability to submit at least one electronic measure (using the QRDA format) in the behavioral health category?

• Yes • No


Informational

AR-BH2 Behavioral Health Staffing

1. Relationships with Behavioral Health Specialist (Shared)

How does your practice address behavioral health needs of patients with the following behavioral health specialists? Check all that apply.

a. Doctors of medicine (MD) or doctors of osteopathy (DO) who are state certified or licensed in psychiatry and/or addiction medicine

Agreements with external behavioral health specialists

Co-location with behavioral health specialist

Behavioral health specialist is integrated within the practice

None of the above

Other_____________

b. Advanced practice registered nurses (APRN) (including nurse practitioners and clinical nurse specialists)




None of the above

Other _____________


Requirement

c. Doctoral or master’s-level psychologists who are state certified or licensed




None of the above

Other _____________

d. Doctoral or master’s-level clinical social workers who are state certified or licensed.



Behavioral health specialist is integrated within the practice)

None of the above

Other _____________

e. Doctoral or master’s-level marriage and family counselors who are state certified, registered or licensed by the state to practice independently.




None of the above

Other _____________

f. Doctoral or master’s-level alcohol and drug counselors who are state certified, registered or licensed by the state to practice independently.




None of the above

Other _____________

2. Relationships with Behavioral Health Specialist (Shared)

Provide a description of the patient “hand-off” process.


Requirement Manual Option

Informational

AR-BH3 Behavioral Health Referral Monitoring

Monitor access to appointments for behavioral healthcare (for all referrals combined).

1. Monitoring Behavioral Health Referrals Scheduled – Data (Site-specific)

Enter:

• Numerator: Number of referrals for which an appointment was scheduled.

• Denominator: The number of initial behavioral health referrals. Include referrals to integrated behavioral health specialists, as well as to specialists in the community.


2. Monitoring Behavioral Health Referrals Seen Within 10 days - Data (Site-specific)

Enter:

• Numerator: Number of completed appointments or patients seen within 10 days of the referral. If the practice has an integrated behavioral health specialist and performs a warm hand-off at the time of the referral (patient is seen by the specialist on the same day the referral is made) this counts as an initial appointment.

• Denominator: Number of initial behavioral health referrals. Include referrals to integrated behavioral health specialists, as well as to specialists in the community.



1. Monitoring Behavioral Health Referrals Scheduled – Data (Site-specific)

Enter:

• Numerator: Number of referrals for which an appointment was scheduled. Search the chart or tracking tool for the 30 behavioral health referrals and report how many had an appointment scheduled.

• Denominator: 30. Pick 30 consecutive behavioral health referrals from the past year (within 12 months prior to the reporting date).


2. Monitoring Behavioral Health Referrals Seen Within 10 days - Data (Site-specific)

Enter:

• Numerator: Number of completed appointments/patient seen within 10 days of the referral. Search the chart or tracking tool for the 30 behavioral health referrals and report how many have appointments were completed or patients were seen within 10 days of the referral.

• Denominator: 30. Pick 30 consecutive behavioral health referrals from the past year (within 12 months prior to the reporting date).



Requirement

Informational

AR-BH4 Depression Screening

The practice provides the following data:

1. Depression Screening – Tool (Shared) Identify tool used to conduct depression screening. • PHQ-2 • PHQ-9 • Other _____________ • None

2. Depression Screening – Patient Population (Site-specific) Define the patients included in the denominator (e.g., certain age groups, people without a history of depression).

3. Depression Screening – Data (Site-specific)

Enter:

• Numerator: Number of patients screened.

• Denominator: Number of patients.


4. Depression Screening & Follow-up - NQF 0418 (Shared) Is your practice using NQF-endorsed Measure 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan to report the numerator and denominator? • Yes • No

Informational

AR-BH5 Anxiety Screening

1. Anxiety Screening – Tool (Shared) Identify tool used to conduct depression screening. • GAD-7 • PC-PTSD • Other _____________ • None

2. Anxiety Screening – Patient Population (Site-specific) Define the patients included in the denominator (e.g., certain age groups, people without a history of depression).

3. Anxiety Screening – Data (Site-specific)

Enter:

• Numerator: Number of patients screened.

• Denominator: Number of patients.


Requirement


Informational

AR-BH6 Behavioral Health Clinical Decision Support

1. Clinical Decision Support – Mental Health (Shared)

Which mental health issues does your practice address with decision support based on evidence-based guidelines? (Note: This requirement focuses on treatment guidelines, not on screening guidelines.)

Depression

Anxiety

Bipolar disorder

ADHD/ADD

Dementia/Alzheimer’s

Other ____________

2. Clinical Decision Support – Substance Use Issues (Shared)

Which topics does your practice address with decision support based on evidence-based guidelines? (Note: This requirement focuses on treatment guidelines, not on screening guidelines.)

Illegal drug use

Prescription drug addiction

Alcoholism

Other _____________


Suggested Plan - Pediatrics The table below provides a suggested plan for what pediatric practices might demonstrate for each virtual check-

in, as well as suggested electives which are highlighted in yellow. A practice may identify other electives that

align with their patient population. This may provide direction for pediatric practices regarding how to approach

the concepts and criteria and reflect input from AAP and pediatric members of the PCMH 2017 Advisory

Committee.

To achieve recognition, practices must:

1. Meet all 40 core criteria and

2. Earn 25 credits in elective criteria across 5 of 6 concepts.

Note that there are 60 potential elective criteria from which to choose, so practices are able to pick and choose the

elective criteria that are most relevant to them. Practices do NOT need to address all 60 elective criteria. The chart

below outlines in blue the elective criteria that pediatric practices have historically found to be more relevant to

them.

Multi-sites: Shared and Site-Specific Evidence

Some evidence can be shared (such as documented processes and demonstration of capability) and may be

submitted once for all sites or site groups. Other evidence (such as evidence of implementation, examples, reports,

Record Review Workbooks and Quality Improvement Workbooks) must be site-specific. Site -specific data may

be combined and submitted once on behalf of all sites or site groups. Some criteria require a combination of

shared and site-specific evidence, which is indicated as partially shared in the tables below.

= Evidence sharable across practice sites

= Evidence that can be partially shared

Core Electives

1 Credit 2 Credits 3 Credits

Total Criteria

(100 criteria) 40 criteria 39 criteria 20 criteria 1 criterion


Competency A: The practice is committed to transforming the practice into a

sustainable medical home. Members of the care team serve specific roles as defined

by the practice’s organizational structure and are equipped with the knowledge and

training necessary to perform those functions

CHECK-IN #

1 2 3

TC 01*

(Core)

PCMH

Transformation

Leads

Designates a clinician lead of the medical home

and a staff person to manage the PCMH

transformation and medical home activities.

TC 02

(Core)

Structure &

Staff

Responsibilities

Defines practice organizational structure and staff

responsibilities/ skills to support key PCMH

functions.


Suggested Plan - Pediatrics

Page 2 of 17

TC 03*

(1 Credit)

External PCMH

Collaborations

The practice is involved in external PCMH-

oriented collaborative activities (e.g.,

federal/state initiatives, health information

exchanges).

TC 04 *

(2 Credits)

Patient/Family/

Caregiver

Involvement in

Governance

Patients/families/caregivers are involved in the

practice’s governance structure or on stakeholder

committees.

TC 05

(2 Credits)

Certified EHR

System

The practice uses an EHR system (or modules)

that has been certified and issued an ONC

Certification ID, conducts a security risk analysis

and implements security updates as necessary

correcting identified security deficiencies.

Competency B: Communication among staff is organized to ensure that patient care

is coordinated, safe and effective. CHECK-IN #

1 2 3

TC 06

(Core)

Individual

Patient Care

Meetings/

Communication

Has regular patient care team meetings or a

structured communication process focused on

individual patient care.

TC 07

(Core)

Staff

Involvement in

Quality

Improvement

Involves care team staff in the practice’s

performance evaluation and quality improvement

activities.

TC 08*

(2 Credits)

Behavioral

Health Care

Manager

Has at least one care manager qualified to identify

and coordinate behavioral health needs.

Competency C: The practice communicates and engages patients on expectations

and their role in the medical home model of care. CHECK-IN #

1 2 3

TC 09

(Core)

Medical Home

Information

Has a process for informing patients/

families/caregivers about the role of the medical

home and provides patients/ families/caregivers

with materials that contain the information.








Page 3 of 17

KNOWING AND MANAGING YOUR PATIENTS (KM)_

Competency A: Practice routinely collects comprehensive data on patients to

understand background and health risks of patients. Practice uses information on the

population to implement needed interventions, tools and supports for the practice as a

whole and for specific individuals.

CHECK-IN #

1 2 3

KM 01

(Core)

Problem Lists Documents an up-to-date problem list for each

patient with current and active diagnoses.

KM 02

(Core)

*F. and G.

are new

Comprehensive

Health

Assessment

Comprehensive health assessment includes (all

items required):

A. Medical history of patient and family

B. Mental health/substance use history of patient

and family

C. Family/social/cultural characteristics

D. Communication needs.

E. Behaviors affecting health

F. Social functioning*

G. Social Determinants of Health*

H. Developmental screening using a standardized

tool. (NA for practices with no pediatric

population under 30 months of age.)

I. Advance care planning. (NA for pediatric

practices)

KM 03

(Core)

Depression

Screening

Conducts depression screenings for adults and

adolescents using a standardized tool.

KM 04*

(1 Credit)

Behavioral

Health

Screenings

Conducts behavioral health screenings and/or

assessments using a standardized tool. (implement

two or more)

A. Anxiety.

B. Alcohol use disorder.

C. Substance use disorder.

D. Pediatric behavioral health screening.

E. Post-traumatic stress disorder.

F. ADHD.

G. Postpartum depression.

KM 05*

(1 Credit)

Oral Health

Assessment &

Services

Assesses oral health needs and provides necessary

services during the care visit based on evidence-

based guidelines or coordinates with oral health



Page 4 of 17

partners.

KM 06

(1 Credit)

Predominant

Conditions &

Concerns

Identifies the predominant conditions and health

concerns of the patient population.

KM 07*

(2 Credits)

Social

Determinants of

Health

Understands social determinants of health for

patients, monitors at the population level and

implements care interventions based on these data.

Resources:

Suggested tools for screening for basic and social

needs: https://www.aap.org/en-us/advocacy-and-

policy/aap-health-

initiatives/poverty/Pages/practice-tips.aspx

KM 08*

(1 Credit)

Patient

Materials

Evaluates patient population

demographics/communication preferences/health

literacy to tailor development and distribution of

patient materials.

Resources:

https://medicalhomeinfo.aap.org/tools-

resources/Documents/LanguageAccessFINAL.pdf

https://medicalhomeinfo.aap.org/tools-

resources/Documents/RI%20FactSheet.pdf

Competency B: The practice seeks to meet the needs of a diverse patient population

by understanding the population’s unique characteristics and language needs. The

practice uses this information to ensure linguistic and other patient needs are met.

CHECK-IN #

1 2 3

KM 09

(Core)

Diversity Assesses the diversity (race, ethnicity and one

other aspect of diversity) of its population.

KM 10

(Core)

Language Assesses the language needs of its population.

KM 11

(1 Credit)

*A. and C.

are new

Population

Needs

Identifies and addresses population-level needs

based on the diversity of the practice and the

community (demonstrate at least 2):

A. Target population health management on

disparities in care. *

B. Address health literacy of the practice.

C. Educate practice staff in cultural competence. *

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/poverty/Pages/practice-tips.aspx



https://medicalhomeinfo.aap.org/tools-resources/Documents/LanguageAccessFINAL.pdf

https://medicalhomeinfo.aap.org/tools-resources/Documents/LanguageAccessFINAL.pdf

https://medicalhomeinfo.aap.org/tools-resources/Documents/RI%20FactSheet.pdf

https://medicalhomeinfo.aap.org/tools-resources/Documents/RI%20FactSheet.pdf



Page 5 of 17

Competency C: The practice proactively addresses the care needs of the patient

population to ensure needs are met. CHECK-IN #

1 2 3

KM 12

(Core)

Proactive

Reminders

Proactively and routinely identifies populations of

patients and reminds them, or their

families/caregivers about needed services (must

report at least 3 categories):

A. Preventive care services.

B. Immunizations.

C. Chronic or acute care services.

D. Patients not recently seen by the practice.

Resource:

AAP Practice Transformation Implementation

Guide: Population Health https://www.aap.org/en-

us/professional-resources/practice-

transformation/Implementation-

Guide/Pages/Population-Health.aspx

KM 13*

(2 Credits)

Excellence in

Performance

Demonstrates excellence in a

benchmarked/performance-based recognition

program assessed using evidence-based care

guidelines. [Specifics yet to be defined but at

minimum includes DRP/HSRP recognition by

NCQA.]

Competency D: The practice addresses medication safety and adherence by

providing information to the patient and establishing processes for medication

documentation, reconciliation and assessment of barriers.

CHECK-IN #

1 2 3

KM 14

(Core)

Medication

Reconciliation

Reviews and reconciles medications for more than

80 percent of patients received from care

transitions.

KM 15

(Core)

Medication

Lists

Maintains an up-to-date list of medications for

more than 80 percent of patients.

KM 16

(1 Credit)

New

Prescription

Education

Assesses understanding and provides education, as

needed, on new prescriptions for more than 50

percent of patients/families/ caregivers.

KM 17

(1 Credit)

Medication

Responses &

Barriers

Assesses and addresses patient response to

medications and barriers to adherence for more

than 50 percent of patients, and dates the

assessment.

https://www.aap.org/en-us/professional-resources/practice-transformation/Implementation-Guide/Pages/Population-Health.aspx






Page 6 of 17

KM 18*

(1 Credit)

Controlled

Substance

Database

Review

Reviews controlled substance database when

prescribing relevant medications.

KM 19*

(2 Credits)

Prescription

Claims Data

Systematically obtains prescription claims data in

order to assess and address medication adherence.

Competency E: The practice incorporates evidence-based clinical decision

support across a variety of conditions to ensure effective and efficient care is

provided to patients.

CHECK-IN #

1 2 3

KM 20

(Core)

Clinical

Decision

Support

Implements clinical decision support following

evidence-based guidelines for care of (must

demonstrate at least 4 criteria):

A. Mental health condition.

B. Substance use disorder.

C. A chronic medical condition.

D. An acute condition.

E. A condition related to unhealthy behaviors.

F. Well child or adult care.

G. Overuse/appropriateness issues.

Competency F: The practice identifies/considers and establishes connections to

community resources to collaborate and direct patients to needed support. CHECK-IN #

1 2 3

KM 21*

(Core)

Community

Resource Needs

Uses information on the population served by the

practice to prioritize needed community resources.

KM 22

(1 Credit)

Access to

Educational

Resources

Provides access to educational resources, such as

materials, peer-support sessions, group classes,

online self-management tools or programs.

KM 23*

(1 Credit)

Oral Health

Education

Provides oral health education resources to

patients.

KM 24

(1 Credit)

Shared

Decision-

Making Aids

Adopts shared decision-making aids for

preference-sensitive conditions.

KM 25*

(1 Credit)

School/

Intervention

Agency

Engagement

Engages with schools or intervention agencies in

the community.



Page 7 of 17

KM 26

(1 Credit)

Community

Resource List

Routinely maintains a current community resource

list based on the needs identified in Core KM 21.

KM 27

(1 Credit)

Community

Resource

Assessment

Assesses the usefulness of identified community

support resources.

KM 28*

(2 Credits)

Case

Conferences

Has regular “case conferences” involving parties

outside the practice team (e.g., community

supports, specialists).








Page 8 of 17

PATIENT-CENTERED ACCESS AND CONTINUITY (AC)

Competency A: The practice seeks to enhance access by providing appointments

and clinical advice based on patients’ needs. CHECK-IN #

1 2 3

AC 01*

(Core)

Access Needs &

Preferences

Assesses the access needs and preferences of

the patient population.

AC 02

(Core)

Same-Day

Appointments

Provides same-day appointments for routine

and urgent care to meet identified patients’

needs.

AC 03

(Core)

Appointments

Outside

Business Hours

Provides routine and urgent appointments

outside regular business hours to meet

identified patient needs.

AC 04

(Core)

Timely Clinical

Advice by

Telephone

Provides timely clinical advice by telephone.

AC 05

(Core)

Clinical Advice

Documentation

Documents clinical advice in patient records

and confirms clinical advice and care provided

after-hours does not conflict with patient

medical record.

AC 06

(1 Credit)

Alternative

Appointments

Provides scheduled routine or urgent

appointments by telephone or other technology

supported mechanisms.

AC 07

(1 Credit)

Electronic

Patient Requests

Has a secure electronic system for patients to

request appointments, prescription refills,

referrals and test results.

AC 08

(1 Credit)

Two-Way

Electronic

Communication

Has a secure electronic system for two-way

communication to provide timely clinical

advice.

AC 09*

(1 Credit)

Equity of Access Uses information on the population served by

the practice to assess equity of access that

considers health disparities.

Competency B: Practices support continuity through empanelment and systematic

access to the patient’s medical record. CHECK-IN #

1 2 3

AC 10

(Core)

Personal

Clinician

Selection

Helps patients/families/caregivers select or

change a personal clinician.



Page 9 of 17

AC 11

(Core)

Patient Visits

with Clinician/

Team

Sets goals and monitors the percentage of

patient visits with selected clinician or team.

AC 12

(2 Credits)

Continuity of

Medical Record

Information

Provides continuity of medical record

information for care and advice when the office

is closed.

AC 13*

(1 Credit)

Panel Size

Review &

Management

Reviews and actively manages panel sizes.

AC 14*

(1 Credit)

External Panel

Review &

Reconciliation

Reviews and reconciles panel based on health

plan or other outside patient assignments.

Resource:

Webpage includes a brief tutorial for how to

compare lists in Excel.

http://tnscriptdoctor.com/excel-tips-and-tricks/










Page 10 of 17


Competency A: The practice systematically identifies patients that would benefit

most from care management. CHECK-IN #

1 2 3

CM 01

(Core)

Identifying

Patients for Care

Management

Considers the following when establishing a

systematic process and criteria for identifying

patients who may benefit from care

management (practice must include at least 3 in

its criteria):

A. Behavioral health conditions

B. High cost/high utilization

C. Poorly controlled or complex conditions

D. Social determinants of health

E. Referrals by outside organizations (e.g.,

insurers, health system, ACO), practice staff

or patient/family/ caregiver

CM 02

(Core)

Monitoring

Patients for Care

Management

Monitors the percentage of the total patient

population identified through its process and

criteria.

CM 03*

(2 Credits)

Comprehensive

Risk-

Stratification

Process

Applies a comprehensive risk-stratification

process to entire patient panel in order to

identify and direct resources appropriately.

Competency B: For patients identified for care management, the practice

consistently uses patient information and collaborates with patients/families/

caregivers to develop a care plan that addresses barriers and incorporates patient

preferences and lifestyle goals documented in the patient’s chart.

CHECK-IN #

1 2 3

CM 04

(Core)

Person-Centered

Care Plans

Establishes a person-centered care plan for

patients identified for care management.

CM 05

(Core)

Written Care

Plans

Provides written care plan to the

patient/family/caregiver for patients identified

for care management.

CM 06

(1 Credit)

Patient

Preferences &

Goals

Documents patient preference and

functional/lifestyle goals in individual care

plans.

CM 07

(1 Credit)

Patient Barriers

to Goals

Identifies and discusses potential barriers to

meeting goals in individual care plans.



Page 11 of 17

CM 08

(1 Credit)

Self-

Management

Plans

Includes a self-management plan in individual

care plans.

CM 09*

(1 Credit)

Care Plan

Integration

Care plan is integrated and accessible across

settings of care.








Page 12 of 17


Competency A: The practice effectively tracks and manages laboratory and

imaging tests important for patient care and informs patients of the result. CHECK-IN #

1 2 3

CC 01

(Core)

Lab & Imaging

Test

Management

The practice systematically manages lab and

imaging tests by:

A. Tracking lab tests until results are available,

flagging and following up on overdue results.

B. Tracking imaging tests until results are

available, flagging and following up on

overdue results.

C. Flagging abnormal lab results, bringing them

to the attention of the clinician.

D. Flagging abnormal imaging results, bringing

them to the attention of the clinician.

E. Notifying patients/families/ caregivers of

normal lab and imaging test results.

F. Notifying patients/families/ caregivers of

abnormal lab and imaging test results.

CC 02

(1 Credit)

Newborn

Screenings

Follows up with the inpatient facility about

newborn hearing and newborn blood-spot

screening.

CC 03*

(2 Credits)

Appropriate Use

for Labs &

Imaging

Uses clinical protocols to determine when

imaging and lab tests are necessary.

Competency B: The practice provides important information in referrals to

specialists and tracks referrals until the report is received. CHECK-IN #

1 2 3

CC 04

(Core)

**

Referral

Management

The practice systematically manages referrals

by:

A. Giving the consultant or specialist the

clinical question, the required timing and the

type of referral

B. Giving the consultant or specialist pertinent

demographic and clinical data, including test

results and the current care plan

C. Tracking referrals until the consultant or

specialist’s report is available, flagging and

following up on overdue reports



Page 13 of 17

CC 05*

(2 Credits)

Appropriate

Referrals

Uses clinical protocols to determine when a

referral to a specialist is necessary.

CC 06*

(1 Credit)

Commonly Used

Specialists

Identification

Identifies the specialists/specialty types most

commonly used by the practice.

CC 07

(2 Credits)

Performance

Information for

Specialist

Referrals

Considers available performance information on

consultants/ specialists when making referrals.

CC 08

(1 Credit)

Specialist

Referral

Expectations

Works with nonbehavioral healthcare specialists

to whom the practice frequently refers to set

expectations for information sharing and patient

care.

CC 09

(2 Credits)

Behavioral

Health Referral

Expectations

Works with behavioral healthcare providers to

whom the practice frequently refers to set

expectations for information sharing and patient

care.

CC 10

(2 Credits)

Behavioral

Health

Integration

Integrates behavioral healthcare providers into

the care delivery system of the practice site.

CC 11

(1 Credit)

Referral

Monitoring

Monitors the timeliness and quality of the

referral response.

CC 12

(1 Credit)

Co-Management

Arrangements

Documents co-management arrangements in the

patient’s medical record.

CC 13*

(2 Credits)

Treatment

Options & Costs

Engages with patients regarding cost

implications of treatment options.

Competency C: The practice connects with other health care facilities to support

patient safety throughout care transitions. The practice receives and shares necessary

patient treatment information to coordinate comprehensive patient care.

CHECK-IN #

1 2 3

CC 14

(Core)

Identifying

Unplanned

Hospital & ED

Visits

Systematically identifies patients with

unplanned hospital admissions and emergency

department visits.

CC 15

(Core)

Sharing Clinical

Information

Shares clinical information with admitting

hospitals and emergency departments.



Page 14 of 17

CC 16

(Core)

Post-Hospital/

ED Visit

Follow-Up

Contacts patients/families/caregivers for follow-

up care, if needed, within an appropriate period

following a hospital admission or emergency

department visit.

CC 17*

(1 Credit)

Acute Care

After Hours

Coordination

Systematic ability to coordinate with acute care

settings after hours through access to current

patient information.

CC 18

(1 Credit)

Information

Exchange during

Hospitalization

Exchanges patient information with the hospital

during a patient’s hospitalization.

CC 19

(1 Credit)

Patient

Discharge

Summaries

Implements process to consistently obtain

patient discharge summaries from the hospital

and other facilities.

CC 20

(1 Credit)

Care Plan

Collaboration

for Practice

Transitions

Collaborates with the patient/family/ caregiver

to develop/ implement a written care plan for

complex patients transferring into/out of the

practice (e.g., from pediatric care to adult care).

CC 21

(Maximum 3

Credits)

External

Electronic

Exchange of

Information

Demonstrates electronic exchange of

information with external entities, agencies and

registries (may select 1 or more):

A. Regional health information organization or

other health information exchange source that

enhances the practice’s ability to manage

complex patients. (1 Credit)

B. Immunization registries or immunization

information systems. (1 Credit)

C. Summary of care record to another provider

or care facility for care transitions. (1 Credit)






CC 21B:

Suggested

Pediatric

Elective



Page 15 of 17


Competency A: The practice measures to understand current performance and to

identify opportunities for improvement. CHECK-IN #

1 2 3

QI 01

(Core)

*D. is New

Clinical

Quality

Measures

Monitors at least five clinical quality measures

across the four categories (must monitor at

least 1 measure of each type):

A. Immunization measures.

B. Other preventive care measures.

C. Chronic or acute care clinical measures.

D. Behavioral health measures. *

QI 02

(Core)

Resource

Stewardship

Measures

Monitors at least two measures of resource

stewardship (must monitor at least 1 measure

of each type):

A. Measures related to care coordination.

B. Measures affecting health care costs.

QI 03

(Core)

Appointment

Availability

Assessment

Assesses performance on availability of major

appointment types to meet patient needs and

preferences for access.

QI 04

(Core)

Patient

Experience

Feedback

Monitors patient experience through:

A. Quantitative data: Conducts a survey (using

any instrument) to evaluate patient/family/

caregiver experiences across at least three

dimensions, such as:

• Access.

• Communication.

• Coordination.

• Whole person care, self-management

support and comprehensiveness.

B. Qualitative data: Obtains feedback from

patients/ families/caregivers through

qualitative means

QI 05

(1 Credit)

Health

Disparities

Assessment

Assesses health disparities using performance

data stratified for vulnerable populations. (must

choose one from each section):

A. Clinical quality

B. Patient experience

QI 06

(1 Credit)

Validated

Patient

Experience

Survey Use

The practice uses a standardized, validated

patient experience survey tool with

benchmarking data available.



Page 16 of 17

QI 07

(2 Credits)

Vulnerable

Patient

Feedback

The practice obtains feedback on experiences of

vulnerable patient groups.

Competency B: The practice evaluates its performance against goals or

benchmarks and uses the results to prioritize and implement improvement

strategies.

CHECK-IN #

1 2 3

QI 08

(Core)

*D. is New

Goals & Actions

to Improve

Clinical Quality

Measures

Sets goals and acts to improve upon at least

three measures across at least three of the four

categories:

A. Immunization measures.

B. Other preventive care measures.

C. Chronic or acute care clinical measures.

D. Behavioral health measures. *

QI 09

(Core)

Goals & Actions

to Improve

Resource

Stewardship

Measures

Sets goals and acts to improve upon at least one

measure of resource stewardship:

A. Measures related to care coordination.

B. Measures affecting health care costs.

QI 10

(Core)

Goals & Actions

to Improve

Appointment

Availability

Sets goals and acts to improve on availability of

major appointment types to meet patient needs

and preferences.

QI 11

(Core)

Goals & Actions

to Improve

Patient

Experience

Sets goals and acts to improve on at least 1

patient experience measure.

QI 12

(2 Credits)

Improved

Performance

Achieves improved performance on at least 2

performance measures.

QI 13

(1 Credit)

Goals & Actions

to Improve

Disparities in

Care/Service

Sets goals and acts to improve disparities in care

or services on at least 1 measure.

QI 14

(2 Credits)

Improved

Performance for

Disparities in

Care/Service

Achieves improved performance on at least 1

measure of disparities in care or service.



Page 17 of 17

New criteria in PCMH 2017.

Competency C: The practice is accountable for performance. The practice shares

performance data with the practice, patients and/or publicly for the measures and

patient populations identified in the previous section.

CHECK-IN #

1 2 3

QI 15

(Core)

Reporting

Performance

within the

Practice

Reports practice-level or individual clinician

performance results within the practice for

measures reported by the practice.

QI 16

(1 Credit)

Reporting

Performance

Publicly or with

Patients

Reports practice-level or individual clinician

performance results publicly or with patients for

measures reported by the practice.

QI 17

(2 Credits)

Patient/Family/

Caregiver

Involvement in

Quality

Improvement

Involves patient/family/caregiver in quality

improvement activities.

QI 18

(2 Credits)

Reporting

Performance

Measures to

Medicare/

Medicaid

Reports clinical quality measures to Medicare or

Medicaid agency.

QI 19*

(Maximum

2 credits)

Value-Based

Contract

Agreements

• Up-Side Risk

Contract

• Two-Sided

Risk Contract

Is engaged in Value-Based Contract Agreement.

(Maximum 2 credits)

A. Practice engages in up-side risk contract (1

credit)

B. Practice engages in two-sided risk contract

(2 credits)







The Impact of Primary Care Practice Transformation on Cost, Quality, and UtilizationA SYSTEMATIC REVIEW OF RESEARCH PUBLISHED IN 2016

PREPARED BY

Made possible with support from the Milbank Memorial Fund

July 2017

The Impact of Primary Care Practice Transformation on Cost, Quality, and UtilizationPAGE 2

AuthorsYalda Jabbarpour, MD, Georgetown University Department of Family Medicine

Emilia DeMarchis, MD, UCSF School of Medicine

Andrew Bazemore, MD, MPH, Robert Graham Center

Paul Grundy, MD, MPH, IBM Watson Health

Contributing AuthorsDonna Daniel, PhD, IBM Watson Health

Irene Dankwa-Mullan, MD, MPH, IBM Watson Health

ReviewersTyler Barreto, MD, Georgetown University Department of Family Medicine/Robert Graham Center

Anshu Choudhri, MHS, Blue Cross Blue Shield Association

Ann Greiner, MCP, Patient-Centered Primary Care Collaborative

Russell Kohl, MD, FAAFP, TMF Health Quality Institute

Christopher F. Koller, Milbank Memorial Fund

Mary Minitti, BS, CPHQ, Institute for Patient and Family-Centered Care

Lisa Dulsky Watkins, MD, Milbank Memorial Fund

Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Peer-Reviewed Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Differences in Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Differences in Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Differences in Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Grey Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Comprehensive Primary Care Initiative (CPCI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Appendix 1.1: Overview of Peer Reviewed Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Appendix 1.2: Summary of Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Figures

Figure 1: Program Spotlight: Blue Cross Blue Shield of Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Figure 2: PRISMA Flow Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Figure 3: Categorization of Included Peer Reviewed Articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Figure 4: Summary of Outcomes: Peer Reviewed Articles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Figure 5: Evaluation of Additional Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Figure 6: Program Spotlight: PACT Enhancements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Figure 7: CPCI and CPC+ Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Figure 8: State Spotlight Colorado. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Figure 9: Program Spotlight: CPCI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Figure 10: State Spotlight Minnesota. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Figure 11: State Spotlight Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Patient-Centered Primary Care Collaborative and the Robert Graham Center PAGE 3

Executive SummaryIn the decade since the “Joint Principles of the Patient-Centered Medical Home”2 were published, it has become widely accepted that primary care practice transformation and delivery are essential to achieving the nation’s Quadruple Aim - improving patient and provider experience and the health of the population while decreasing cost. Over that same time span, evidence that lights the path towards transformation, of the sort best suited to accomplishing these aims and realizing high-performing primary care, continues to emerge.

As this year’s evidence report reaffirms,

the Patient-Centered Medical Home (PCMH)

has demonstrated improved outcomes in

terms of quality, cost and utilization, but

not uniformly. It also confirms important lessons for payers and policymakers: like any form of evolution, meaningful transformation takes time, is dynamic in nature, and displays considerable variations in quality, cost and utilization outcomes. The evidence also reveals some concrete modifications to the initial model, learned from best practice PCMHs over the past 10 years, which have improved primary care and its outcomes. For example, it is quite clear that team-based interventions, including case management, and having a usual source of care have positively impacted the patient experience. That said, there is no single ‘implementation manual’ that meets the needs of all.

CHANGES TO THE REPORT

This update to the Patient-Centered Primary Care Collaborative (PCPCC) annual report, led by a new team of investigators, remains true to its predecessors in aims and spirit, with several differences worth noting. Its

PCPCC, Milbank Memorial Fund, and Robert

Graham Center planners declared early an

intent to broaden the gaze of the review

to capture any evidence relevant to ‘high

performing primary care,’ not merely the

PCMH, to broaden the bibliometric data sources reviewed, and to apply rigorous methods of both peer-reviewed and grey literature systematic review. An agreed upon standardized definition of high performing primary care remains a work in progress. That said, a coalition of about 300 leaders across diverse stakeholder groups came together to create the 2017 Shared Principles of Primary Care. These Shared Principles, to be released in October 2017, define the most important features of advanced primary care. Some of the seven Shared Principles are already evident in leading practices across the country: the full collection of Shared Principles represent an aspirational goal for primary care.

The report takes a featured look at Blue Cross Blue Shield of Michigan, which leads one of the oldest PCMH programs, now in its eighth year with seven years of data. Important to note, the Michigan experience is

one of the largest, with 4,534 primary care

doctors at 1,638 practices and with published

peer-reviewed reports. The statewide

transformation of care has resulted in a 15%

decrease in adult Emergency Department

(ED) visits and a 21% decrease in adult

ambulatory care sensitive inpatient stays.3 That these returns contrast considerably with those reported in the past year from near-neighbor Pennsylvania reinforces the notion that primary care transformation efforts can vary significantly not only in approach, but in outcomes.

OUR RESEARCH APPROACH

To broadly assess the landscape, we systematically reviewed evidence from the last year of peer-reviewed and grey literature that analyzed value of care delivered in terms of cost, quality and

The PCMH model has evolved and new models of high performing primary care are emerging. This dynamism is exciting but assessment and scaling is challenging.

DIFFERENCES

IN COST

Take home: In general, the PCMH showed a decrease in

overall cost, with a more positive trend for more mature PCMHs and for those patients with more complex medical conditions .

PAGE 4 The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization

utilization of purported high-performing primary care practices across the nation. We divided our peer-reviewed analysis into subgroups of studies that looked at PCMH outcomes and those that looked at practices who attempted to transform the delivery of care in novel ways, but who weren’t necessarily a PCMH. For each group, we studied the effects on quality, cost and utilization. A total of 45 reports from the

peer-reviewed literature were assessed. We

then turned our attention to outcomes from

CMS initiative reports and independent

state evaluations, once again reporting on

the effects on cost, quality and utilization.

HIGHER QUALITY AT LOWER COST

That systems and organizations built around a core primary care function can deliver higher quality, lower cost and more equitable care is well-established, not only by Barbara Starfield,4 a seminal figure in health services research, but in previous findings from other countries and evaluations of microsystem transformation within the U.S.5,6,7,8 The challenge is one of scaling the

most effective processes, principles and

cultures of transformation. In that context, we placed particular emphasis on findings from two Medicare innovation programs: the Comprehensive Primary Care Initiative (CPCI) and the Multi-Payer Advanced Primary Care Practice (MAPCP) transformation.

Over the past year, peer-reviewed studies on the impact of primary care practice transformation on cost generally supported the idea that becoming or advancing one’s

status as a PCMH was associated with

decreases in overall cost. This association was stronger for mature PCMHs and for those caring for patients with more complex medical conditions. Interestingly, the CPCI reports showed less favorable cost outcomes. Although the average per beneficiary per month (PBPM) Medicare expenditures were lower for CPC attributed patients as opposed to controls, the savings were not enough to offset the care management fees paid PBPM.

When looking at individual states, such as Oregon and Colorado, cost savings were seen, but it is difficult to parse out the effects of CPCI from other state initiatives and grants that were running concurrently. One would expect that if costs decreased, utilization outcomes should have also been more homogenously favorable. This discrepancy could be attributed to the varying costs for different measures of utilization. For example, the state evaluators from Colorado commented that overall costs decreased despite mixed utilization results because inpatient hospitalizations, presumably the driver of most healthcare costs in their system, decreased.9

In the context of efforts to leverage primary care to shift the overall health system from volume towards value, we discovered some

positive quality results across nationwide

evaluations but not in every instance. State-specific data showed either a trend towards a positive effect on outcomes, or no effect on quality outcomes. In the peer-reviewed literature, the positive quality outcomes varied greatly as few studies reported on the same quality measures in the same way. This may have less to do with flaws in study design or validity, and more to do with a need for more harmonized measures in general. Interestingly, all reports that commented on the patient experience showed positive quality results. Overall, studies this year showed us that the longer a practice had been transformed, and the higher the risk of the patient pool in terms of comorbid conditions, the more significant the positive effect of practice transformation.

We found no studies this year that reported specifically on the impact of the PCMH on provider satisfaction, yet two systematic reviews examined interventions to reduce physician burnout in general. These studies showed that organizational changes aimed at fostering a culture of teamwork, a key component of the PCMH, could lead to reductions in physician burnout.73,74 Previous studies have also shown that other features of advanced primary care practices such as scribes and enhanced teams also contribute

DIFFERENCES

IN QUALITY

Take home: Effects on quality are mixed but,

excluding one outlier, were either positively correlated with PCMH or showed no difference in quality measures from control . Like the data for utilization, heterogeneity in study design and measures studied could account for these differences . All the studies that examined the patient experience showed positive outcomes .


to patient satisfaction and efficiency.75,76 A deeper dive into the effect of the PCMH on provider satisfaction would be an important addition to next year’s report as we move towards the Quadruple Aim of providing high quality care and increasing patient and provider satisfaction while containing costs.

When looking at utilization outcomes, the

peer-reviewed studies overall showed an

increase in PCP use for patients enrolled

in the PCMH when compared to those

who are not. The data are inconsistent on

whether this increase in PCP use leads to a

concomitant decrease in specialty services,

ER utilization, or hospitalizations for PCMH

attributed patients. The CPCI and MAPCP reports also report mixed outcomes on appropriate utilization of services, with some states showing more favorable outcomes than others. The heterogeneity of study design, the differences in populations studied, as well as the varying implementation of PCMH (both in terms of actual practices and maturity) could explain the inconsistent results.

This year, many studies started to investigate the impact of primary care enhancements on previously transformed practices. Many of these studies focused on the impact of adding team members such as case managers or pharmacists to their already-transformed practices. These studies showed promising results, and demonstrated that we

are exiting an era of evaluating the impact of

the PCMH into an era of continuing evolution

of high performing primary care.

HIGHLIGHTS FROM THIS EVIDENCE REVIEW

• New this year, we attempted to include quality outcomes in addition to cost and utilization. Peer-reviewed, CMS-initiative and state-specific data showed either a trend towards a positive effect on quality, or no impact on quality, though few results were statistically significant. The positive outcomes varied greatly as few studies reported on the same quality measures in the same way. This may have

less to do with flaws in study design or validity and more to do with a need for more harmonized outcomes measures, in general.

• All studies that reported on patient satisfaction showed positive results.

• Team-based interventions, including case management, and having a usual source of care have positively impacted the patient experience.

• Overall, analysis of the studies revealed that the longer a practice had been transformed, and the higher the risk of the patient pool in terms of comorbid conditions, the more significant the positive effect of practice transformation, especially in terms of cost savings. While nationwide evaluations of CPCI and MAPCP showed less significant impacts of cost, evaluations of state-specific programs did show cost savings. CPCI and MAPCP participants noted that, in general, without payments from the federal government, cost savings would not be sufficient to cover the costs associated with transformation and continued implementation of their programs. Few peer-reviewed studies that showed cost savings commented on the cost of transformation or whether they took this into consideration in their analysis.

• Utilization outcomes were mixed. While most studies and state reports did show an increase in outpatient visits, this didn’t uniformly result in a concomitant decrease in ER visits or inpatient stays.

• A best practice PCMH program, Blue Cross Blue Shield of Michigan, is featured. See Figure 1. Blue Cross Blue Shield of Michigan leads one of the oldest PCMH programs, now in its eighth year with seven years of data. Important to note, the Michigan experience is also one of the largest, with 4,534 primary care doctors at 1,638 practices. The statewide transformation of care has resulted in a 15% decrease in adult ED visits and a 21% decrease in adult ambulatory care sensitive inpatient stays.2

Implementation of primary care reform models differ; there is no one size fits all.

DIFFERENCES

IN UTILIZATION

Take home: Overall, data on utilization of services is

mixed, but trends towards positive findings . Studies tend to show an increase in PCP use but the data is inconsistent on whether this increase in PCP use leads to a concomitant change in specialty services, ER utilization, or hospitalizations .


FIGURE 1

Program Spotlight: Blue Cross Blue Shield of Michigan

LESSON #3

Spark physician enthusiasm

“Relentless incrementalism” is a PGIP motto, and PGIP initiatives are designed to support and reward step-by-step progress through the celebration of provider and program best practices at quarterly meetings .

LESSON #6

Encourage multi-payer participationThe PGIP program provided the foundation for the five year Michigan Multi-Payer Advanced Primary Care Practice Demonstration program .

LESSON #9

Establish realistic time tables for evaluationUnderlying the PGIP philosophy of relentless incrementalism is the understanding that practice transformation is a long-term process, and programs must be allowed to stabilize and mature before results are evaluated .

LESSON #1

Nurture effective and stable leadershipThe Physician Group Incentive Program (PGIP) has catalyzed the formation of over 40 Physician Organizations (POs) that have led and supported practices in revolutionizing the delivery of health care in Michigan .

LESSON #4

Demand federal commitment, action and coordinationPGIP medical leaders have testified before Congress regarding the value-based reimbursement model and the importance of the federal government supporting and recognizing regional practice transformation efforts .

LESSON #7

Offer technical assistance and collaborative learningPGIP provides practices with technical assistance and opportunities for collaborative learning by hosting learning collaboratives, providing education and guidance and funding a Care Management Resource Center .

LESSON #10

Obtain timely, accessible and useful dataThe PGIP PCMH/PCMH-N program provides financial support to POs and practices to build the capacity for population management through use of integrated patient registries and performance reporting .

LESSON #2

Gather together (get everyone around the table)BCBSM’s facilitation of quarterly meetings with all PO leaders (approximately 350) has led to cross-collaboration and synergistic partnerships among providers across the state, as well as the formation of a Primary Care Leadership Committee that provides review and guidance on PGIP policies and programs .

LESSON #5

Offer meaningful financial supportThe PGIP program has used a combination of incentive reward payments to POs and value-based reimbursement for individual physicians to ensure providers have the financial support needed to succeed .

LESSON #8

Embrace team-based approaches that extend beyond the practicePOs and practices deliver multi-disciplinary team-based care through access to a Provider-Delivered Care Management (PDCM) program, behavioral health providers and embedded pharmacist care managers .

Blue Cross Blue Shield of Michigan has the largest and longest running Patient Centered Medical Home . A key to their success, as outlined here, has been using lessons learned from other advanced primary practices71 as the building blocks77 for their practice transformation .


Background

TRANSFORMING PRIMARY CARE PRACTICE: WHAT IS KNOWN

The “Joint Principles of the Patient Centered Medical Home,” developed in 2007, created a blueprint for a primary care delivery system that could bend the cost curve of health care while simultaneously improving patient outcomes and the patient experience. A decade since these principles were set, the PCMH model has spread throughout the United States: 44 states and the District of Columbia have passed or introduced at least 330 laws to define or demonstrate the medical home concept and it is estimated that 45% of family physicians practice within a PCMH.10 Although the concept of the PCMH is widespread, the framework used to transform practices and the specific interventions made within each framework have widely varied, as have their impacts on health care cost, quality and utilization.

With a shifting political landscape comes inevitable discussion of a potential change in healthcare access, delivery and finance. It is more important than ever to critically evaluate transformed practices and to understand their true impact on the health care system. Previous analysis performed by the PCPCC and others have summarized successful PCMH initiatives across the country. The analysis has shown that the PCMH has moved our healthcare system closer to the Quadruple Aim of enhancing the patient and provider experience, and improving the health of the population while containing costs.11,12,13,14 In particular, if one looks at data from the PCMH transformation program in Michigan, the largest state-level

implementation program in the United States to date, the success of the medical home is evident.11,12,13

The PCMH transformation program in Michigan has shown:

• Practices that have fully implemented the PCMH model have expected savings of $26.37 lower per member per month adult medical costs13

• Implementation of a PCMH was associated with higher breast, cervical and colorectal cancer screening rates for Michigan PCMH patients regardless of socioeconomic status15

• Both level and amount of change in PCMH practices is positively associated with quality of care and use of preventive services13

• Hospital utilization was reduced by 13.9 percent for PCMH-targeted conditions versus only 3.8 percent for other conditions (p = .003)11

• ED utilization decreased by 11.2 percent for PCMH-targeted conditions versus 3.7 percent for other conditions (p = .010)11

• Hospital PMPM cost was reduced by 17.2 percent for PCMH-targeted conditions versus only 3.1 percent for other conditions (p < .001)11

• ED PMPM cost decreased by 9.4 percent for PCMH targeted conditions versus 3.6 percent for other conditions (p < .001)11

Glossary

ACCAccountable Care Collaborative

BPBlood pressure

CCOCollaborative Care Organization

CMMICenter for Medicare and Medicaid Innovations

CMSCenters for Medicare and Medicaid Services

CPCIComprehensive Primary Care Initiative

HCHHealth Care Homes

ITInformation technology

MAPCPMulti-Payer Advanced Primary Care Practice

NCQANational Committee for Quality Assurance

PBPMPer beneficiary per month

PCMHPatient-Centered Medical Home

PCPPrimary Care Physician

PCPCHPatient-Centered Primary Care Home

Safety NetCalifornia’s safety net is a patchwork of programs and providers that serve people with low incomes, no private insurance coverage, or other special needs . Not all safety nets are under the umbrella of Federally Qualified Health Centers .1*

VA PACTVeterans Affairs Patient Aligned Care Team


Other evaluations have shown a less sizeable return for their investment:

• In Pennsylvania, pilot participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multi-payer medical home pilots conducted in the United States, was associated with statistically significantly greater performance improvement on only 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care.16

• A recent systematic review in Health Affairs, examining cost and quality outcomes of PCMH initiatives in 11 regions across the country, showed that although PCMH initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, they were not associated with changes in the majority of outcomes studied, including primary care, ED, and inpatient visits and four quality measures.17

Given the substantial cost and time needed for practice transformation,18 it is essential to continue to understand the impact of the PCMH as practices nationwide continue to adopt its principles. To this end, our goal this year was to objectively and systematically study the literature on PCMH and advanced primary care models published over the last year with a special focus on determining and analyzing their true impact on cost, quality and utilization.

STRUCTURE OF CURRENT REPORT

Our current report is divided into two main sections: an analysis of peer-reviewed literature and an analysis of the grey literature. (We defined grey literature as

evaluations of PCMH that had not been published in peer-reviewed format, but still presented some discussion of study design and/or methodology when presenting results. These included state reports, industry reports and multi-payer evaluations.)

Our primary outcomes of cost, quality and utilization are discussed within each section. We expanded our search criteria to include practices that were formally labeled as a PCMH, as well as advanced primary care practices that had features of a PCMH without being formally labeled as such. In our review of the literature, we label the former as “PCMH Implementation” and the latter as “Features of PCMH Care Delivery Studies.” We also identified articles that studied enhancements to established PCMHs and we label those as “PCMH Enhancement Studies.”

The grey literature this year was limited to pieces published between November 1, 2015 to February 28, 2017 that had some discussion of study design and methods when reporting findings, but had yet to be published in formats other than reports. This limited our use of many industry sponsored reports and some state sponsored reports. The final CPCI and MAPCP reports are included here, as are state reports from Colorado, Minnesota and Oregon.

Compared with the 2014-2015 report, our expanded inclusion criteria resulted in a notable increase in articles, especially those using quality as an independent outcome (sixteen studies reported on quality alone). In last year’s peer-reviewed studies, articles that utilized chart review/claims data were reviewed in combination with those using survey data, whereas we chose to separate out survey data into the features of PCMH care delivery, given we were unable to verify that care deemed PCMH-like by survey respondents actually occurred within a PCMH.

A decade since the Joint Principles were set, the PCMH model has spread throughout the United States: 44 states and the District of Columbia have passed or introduced at least 330 laws to define or demonstrate the medical home concept and it is estimated that 45% of family physicians practice within a PCMH.


Methods

APPROACH

Before beginning our systematic review, we reviewed previous systematic reviews on the PCMH including previous PCPCC Annual Evidence Reports. We also identified and contacted content experts, including past authors of those reports, to request their input on our proposed definitions, MESH headings and search terms, databases to include, and approach. With this input, we compiled a list of relevant bibliographic databases deemed appropriate to search, and narrowed our definition and strategy for extracting grey literature of scholarly value.

We explored several search engines in the process and modified our original date restrictions, limited to calendar year 2016, to a slightly wider date range of November 1, 2015 to February 28, 2017. This was done to create a search continuum from the end of the date range searched in the previous PCPCC annual evidence review through the latest date that could be accommodated by our own project calendar, in hopes of releasing the most contemporary evidence available in this dynamic content area. We also limited our search to studies available in the English language.

To improve the rigor of our methods and search, we finalized both under consultation with two library scientists, one from the American Academy of Family Physicians (AAFP) and the other from Georgetown Medical Dahlgren Memorial Library (KD and GC). Institutional review board approval was not applicable. The focus of the search terms was on capturing articles evaluating the PCMH and/or high performing primary care metrics by the main study outcomes of cost, quality and/or utilization.

BIBLIOGRAPHIC DATABASES

For the peer-reviewed articles, PubMed MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched. For grey literature, Web of Science (screening for non-peer-reviewed articles), ProQuest, Open Grey, Metalab, data.gov, openDOAR, and EPPI-Centre were utilized. Additional grey literature was reviewed using Kaiseredu.org, National Academy for State Health Policy (NASHP), the Agency for Healthcare Research and Quality (AHRQ), and the World Health Organization (WHO).

An initial review of conference abstracts and presentations from the 2016 American Academy of Family Physicians (AAFP), North American Primary Care Research Group (NAPCRG), Academy Health, Society of Teachers of Family Medicine (STFM), and Institute for Healthcare Improvement (IHI) conferences was performed, but conference material was ultimately excluded from this review, due to a lack of consistently accessible text.

GREY LITERATURE

Grey literature, or “that which is produced on all levels of government, academics, business and industry in print and electronic formats, but which is not controlled by commercial publishers” likely outnumbers the peer reviewed literature in quantity, but exists outside of the traditional academic publishing channels that feed the bibliographic databases listed above.19 Given the novelty and dynamic nature of primary care practice transformation studied, inclusion of the grey literature was deemed an important source of information for this review synthesis. Furthermore, systematic reviews based on traditional bibliographic


databases may be subject to “publication bias,” as studies with more positive results are several times more likely to be published than ones which show little or no positive effect for an intervention.20 Including grey literature in a systematic review can unearth unpublished trials demonstrating interventions which resulted in neutral or negative findings, potentially significantly impacting the conclusions of a systematic review. However, many characteristics of grey literature make it difficult to search systematically, and there is no ‘gold standard’ to guide rigorous grey literature search methods.

We used past systematic reviews on the PCMH and expert opinion to guide our approach.10 We considered multiple search strategies and engines, and settled on Google Scholar and Advanced Google searches to screen for state published and industry reports from November 1, 2015 to February 28, 2017. Six state-based and three industry reports were identified. Three of the state-based reports met our inclusion criteria and quality evaluation for inclusion; none of the industry reports were included due to inability to confirm methods. More specifically, the reports published directly from the state governments or industries did not always have full information on how outcomes were measured, who the comparison group was or whether their results met statistical significance, and were thus excluded. Four independent reviews of federal initiatives (by RTI or Mathematica) met our study criteria.

One author (EHD) screened 1,278 PubMed, 22 EMBASE, 1 CINAHL, 16 Web of Science, and 194 ProQuest articles after screening for duplicates between the databases (see Figure 2 for PRISMA flow diagram). There were no non-duplicate relevant Cochrane Library, Open Grey, Metalab, data.gov, openDOAR, EPPI-entre, Kaiseredu.org, NASHP, AHRQ, or WHO articles for the review.

FIGURE 2

PRISMA Flow Diagram

PubMed search

(n=1,278)

Records after duplicates removed

(n=1,511)

• PubMed: 1,278• EMBASE: 2• CINAHL: 1• Web of Science: 16• Proquest: 194

Records excluded (n=1,184)

• Unrelated to topic (n=1,037)

• Background information only, not full studies (n=142)

• Included last year (n=5)

Full-text articles excluded

• Inadequate focus on high functioning primary care (n=48)

Records screened (n=1,511)

Full-text articles assessed for eligibility

(n=94)

Included (n=46)

EMBASE search (n=36)

CINAHL search (n=36)

Web of Science search (n=324)

Proquest search (n=194)

RECORDS IDENTIFIED THROUGH:


Two authors (YJ and EHD) reviewed 94 full text peer-reviewed articles, with 45 peer-reviewed articles included in the final review; thirteen grey literature articles and independent reviews of federal initiatives were reviewed by both authors, with five being included in the final review. Articles were excluded if they did not focus on either a PCMH or high performing primary care initiative (encompassing a focus on any of the seven elements of a PCMH), and cost, quality and/or utilization outcomes.

Throughout the process we engaged secondary reviewers (AB, MC, PG, AG, RS) to help review our search decisions and to conduct independent reviews of selected article types that were on the threshold for inclusion or exclusion. Furthermore, we engaged an advisory group in the form of tertiary reviewers to ensure that additional articles of value weren’t excluded and to gauge the merit of threshold articles.

ELIGIBILITY CRITERIA

Inclusion criteria was defined as studies that evaluated the PCMH or other practices with PCMH features and looked at quality, utilization or cost outcomes.

We identified 45 peer-reviewed reports published from November 1, 2015 through February 28, 2017 that met our inclusion criteria; 17 studies evaluated PCMH implementation initiatives versus traditional care (hereby referred to as PCMH implementation); 15 studies evaluated features of the PCMH model, taken as proxies for aspects of high performing primary care without formal PCMH recognition or a method to verify that care was within a PCMH (hereby referred to as features of PCMH care delivery); and 13 studies evaluated enhancement initiatives within an established PCMH versus baseline PCMH care (hereby referred to as PCMH enhancement), and are

discussed separately under the section on PCMH enhancement. See Appendices 1.1 and 1.2 for specific details on individual studies.

PCMH Implementation Studies

Of the PCMH implementation studies, eight were multi-state or regional initiatives,21,22,23,24,25,26,27,28 with five utilizing NCQA PCMH standards (primarily 2008 standards),21,22,23,24,25 two occurred within populations that defined themselves as medically underserved with unspecified PCMH recognition type,20,26 and one study focused on a Veterans Administration Patient Aligned Care Team (VA PACT).27 Seven of the eight studies evaluated the transformed PCMH setting against a control (traditional care), with some additional pre-/post-transformation analyses; the VA PACT study evaluated only pre-/post-PACT transformation, and was also the only regional PCMH study that included data before 2007, owing to the utilization of pre-PCMH transformation data.

Five studies were state-based PCMH initiatives, with four being state-specific Medicaid PCMH programs,29,30,31,32 and only one a multi-payer state initiative (Minnesota Health Care Home [MN HCH]).33 All but the Carlin et al. MN HCH report evaluated patients from the PCMH initiatives against a traditional care cohort; Carlin et al. evaluated outcomes based on stage of PCMH transformation (distinguished as early, intermediate or late stage). Four studies were insurance or health system PCMH initiatives, three from BlueCross BlueShield34,35,36 and one from Geisinger Health System.37

The majority of articles reviewed utilized data from 2008 through 2013, with a couple outliers, including the VA PACT study noted above (using pre- and post-PACT implementation data from 2003 to 2013),27 and a state Medicaid PCMH program that was conducted from 2005 through 2010.29


Only two implementation studies, both NCQA-certified regional PCHM inititives, reported on all three of our report outcomes (utilization, cost and quality),21,25 both NCQA-certified regional PCMH initiatives. Five studies focused on utilization20,27,31,32,33 alone (two regional,27,20 two state-based31,32 and one insurance-based33 initiative). Two insurance or health system-based initiatives reported only on cost.34,35 Four studies reported only on quality (three regional23,24,26 and one insurance-based initiative).33 Cost and utilization were both reviewed in three state-based initiatives,28,29,30 and one regional NCQA initiative reported on utilization and quality.22

Features of PCMH Care Delivery Studies

Of the studies evaluating features of PCMH care delivery, eight utilized survey data,38,39,40,41,42,43,44,45 four of which used Medical Expenditure Panel Survey (MEPS) data to distinguish a usual source of care (USOC) from elements of PCMH-type care,37,40,42,43 and one study each used the safety-net medical home survey (SNMHS),39 Massachusetts Behavioral Risk Factor Surveillance System (MA-BRFSS) survey,36 the National Ambulatory Medical Care Survey (NAMCS),41 and the National Survey of Children with Special Health Care Needs (NSCSHN) survey.38 The remaining seven studies included a mix of chart review or claims data, evaluating elements of a medical home without noted PCMH recognition. Two of the studies were of pediatric populations,38,46

two included only breast cancer patients,47,48 two focused on mental health,40,47 one took place within the safety-net,49 and one was a Canadian study evaluating team-based care and alternative payment structures.50

Similar to the PCMH implementation studies, the majority of articles examining features of PCMH care delivery had study dates ranging from 2007 through 2014, but

with variability. The Kern et al. Canadian study compared data from 2001 and 2011,52 a study of breast cancer patients enrolled in PCMHs took place from 2003 through 2007,46 and one study did not specify dates.47 Of note, one of the four studies using MEPS data included 2004 survey data (full study period 2004-2011)40 when it was less feasible to distinguish PCMH-type care; the study was still included, given the majority of data was collected post-2004.

None of the features of PCMH care delivery reviewed all three report outcomes. Four studies reported on only utilization,38,40,51,52

and seven studies reported on only quality.36,37,39,41,44,45,48 Only one reported on cost,46 reviewing both cost and utilization. Only two studies reported on both utilization and quality.42,47

PCMH Enhancement Studies

The thirteen PCMH enhancement studies focused primarily on team-based care interventions, including two studies evaluating pharmacy interventions,53,54 one evaluating a team-based approach to mental health,55 and three studies looking at complex care and case management.56,57,58

One study evaluated the impact of an alternative payment model59 and two focused on information technology (IT) interventions.60,61 Five of the articles took place in NCQA-certified PCMH initiatives (2008 or 2011 standards)51,53,54,59,62 and four within a VA-PACT.55,56,59,63 The remaining articles noted that they occurred in a PCMH, but did not specify type of recognition or accreditation. All studies that specified a timeframe took place between 2008 and 2014; one study did not note the study time frame.58 It is expected that studies would not include data pre-2008, given that they all focused on initiatives within already established PCMHs.

FIGURE 3

Categorization of Included Peer Reviewed Articles

PCMH Implementation StudiesPCMH vs traditional care(n=17)

Features of PCMH Care Delivery StudiesNon-PCMH or not mentioned if PCMH but with PCMH like features as compared to traditional care(n=15)

PCMH Enhancement StudiesMature PCMH’s that study the impact of specific PCMH components (i .e . team based care, telehealth)(n=13)


Findings

PEER-REVIEWED STUDIES

Overall, our review demonstrated mixed results in terms of cost, quality and utilization outcomes. The PCMH enhancement studies, outlined in Figure 5, had the most encouraging findings.

Differences in Cost

Take home: In general, the PCMH showed a decrease in overall cost, with a more positive trend for more mature PCMHs

and for those patients with more complex medical conditions .


Seven of the PCMH implementation studies reported on cost, with a trend toward cost savings. Only one of the seven studies demonstrated increased overall cost,21 with another study showing statistically significant increased costs only for patients with comorbid chronic and mental health conditions, but not overall.28 The Flieger article that reported higher costs was also notably the only study evaluating cost over only a single year of data. Five of the PCMH transformation studies showed a reduction in cost,36,29,30,34 though one lacked statistical significance.25 When reported on, clinics showed increased cost savings over time and with increasing chronic conditions.28,30,34,64 This suggests it takes time for cost savings to be realized, and patients with more chronic conditions can have the most cost savings when in a PCMH, which is not unexpected given that patients with more complex medical conditions could be seen as having the most to gain from patient-centered, coordinated care.31,33

Studies that reported on both cost and utilization showed varying results. For one NCQA initiative evaluating outcomes over four years,25 there was a reduction in ambulatory-care sensitive ED visits (0.7 per 1000 member months), with no difference in PCP, specialty, overall ED visits or inpatient admissions, and a non-significant reduction in cost (reduction in total cost of care of $7,679 per 1,000 member months). In the Flieger NCQA initiative,21 there were no statistically significant differences in any utilization or quality metric, but increased total costs (excluding pharmacy). The increased costs of care could be attributed to previously unfilled demand, especially given the single year of data analyzed, and long-term outcomes remain to be seen. Two of three Medicaid PCMH initiatives that evaluated both cost and utilization29,30

showed a decrease in utilization and a corresponding decrease in costs.


Only one article reported on cost, with the Kohler et al. article noting increased cost.46 The Kohler article was a Medicaid PCMH initiative focused only on breast cancer patients, and reported higher outpatient PCP and non-oncology specialty care services, but no impact on ED visits or hospitalization, and higher unadjusted monthly Medicaid costs, likely attributable to the increase in outpatient utilization. The Kohler et al. study utilized data from 2003 to 2007, being the oldest data set of all the peer-reviewed articles in this report.


Team-based care enhancement programs had neutral to positive effects on cost. Of the three team-based care intervention studies that examined cost, one noted an increase in person-level costs without impacting other costs within a VA PACT,56

Studies on quality suggest that having a consistent clinic (usual source of care) may be one of the most impactful features of the PCMH.


and two NCQA PCMH studies showed lower overall revenue.54,60 Both studies that showed lower revenue from insurance payments also showed improvement in quality measures.54,60 Salzberg et al.’s risk-adjusted payment structure study showed no impact on overall cost,57 though did show reduced pharmaceutical expenditures especially among patients with more medical co-morbidity; in the report, one of the two IT interventions reported reduced healthcare costs within a VA PACT.59 While the Salzberg study didn’t comment on quality, the VA PACT article showed improvements in both quality and utilization.57,59

Differences in Quality

Take home: Effects on quality are mixed but, excluding one outlier, were either positively correlated with PCMH or showed no

difference in quality measures from control . Like the data for utilization, heterogeneity in study design and measures studied could account for these differences . All the studies that examined the patient experience showed positive outcomes .

Quality, being a difficult metric to define and evaluate due to inconsistencies in how data is collected or reported on, is a highly important core component of the Quadruple Aim, and thus included as its own outcome in this year’s report.

Given that the quality measures studied in the peer reviewed literature were not harmonized, results were generally mixed. Interestingly, the studies that looked at patient satisfaction as a secondary outcome, though limited in number, did all show positive results. The three studies that examined the patient experience showed higher rates of patient satisfaction for patients in the PCMH enhancements group.38,55,57 Two of these studies examined

adding a case manager to the PCMH, and one looked at the impact of usual source of care.

In addition, two systematic reviews this year looked at physician burnout.73,74 Although these studies were not looking at the PCMH specifically, they found that organizational elements common to many PCMH’s reduced physician burnout. Specifically, the practices that fostered communication between members of the health care team, and cultivated a sense of teamwork were more likely to reduce physician burnout.74


Seven of the PCMH implementation initiatives reported on quality, using a variety of metrics. Five of the studies reported on receipt of preventive services, most typically, but not exclusively,

FIGURE 4

Summary of Outcomes: Peer Reviewed Articles

Number of articles reporting: Positive results Mixed results Negative results

Cost (n=13)

8

2

3

Quality (n=24)

11

11

2

Inpatient Utilization (n=6)

3

3

ED Utilization (n=10)

6

3

1

PCP Utilization (n=7)

6

1


comprised of: breast, colon and cervical cancer screening; flu vaccinations; and routine diabetic management (hemoglobin A1C, cholesterol and nephropathy screening).21,22,23,25,26 One study each reported on only medication adherence24 and only post-discharge follow-up.20 Overall, there were highly mixed results in terms of quality. Two studies demonstrated an increase in over half of the quality metrics measured, whereas another showed

increased lipid screening in diabetic patients only25 (out of six quality metrics reviewed), and the Flieger study of eight quality metrics showed no statistically significant improvements in any measure over the one year study period.21 The majority of studies showed no significant difference in quality, or differences only for very specific patient populations. Of the studies evaluating only one quality metric, PCMH transformed clinics showed improved medication adherence24 and an increase in percentage of patients seen within 7 days of hospital discharge.33 Notably, despite being seen within 7 days, these patients were seen by their PCP for the discharge visit less frequently than the comparison group . There was no uniformity between articles in terms of quality metrics measured, which likely contributes to the mixed quality outcomes between articles.21,24,33

For the two studies evaluating cost, utilization, and quality, the Flieger article, as mentioned previously, showed no statistically significant outcomes in utilization or quality, but increased cost.21 The Rosenthal et al. article had a drop in ambulatory care-sensitive ED visits, but no overall utilization changes, no statistically significant impact on cost, and an increase in lipid screening for diabetic patients only.25 Kern et al. analyzed both utilization and quality, demonstrating that increased PCP visits did not correlate to a statistically significant improvement in quality metrics.22


Ten of the 15 studies that focused on features of a PCMH reported on quality.36,37, 39,41,42,,43,44,45,47,48 Similar to the PCMH transformation studies, quality metrics differed between studies, with five studies measuring receipt of preventative screening.39,41,44,45 One study reported on breast cancer screening alone,45 another on diabetes care alone,39 one on a variety of care process measures,41 and another

FIGURE 5

PCMH Enhancement Studies : Evaluation of Additional Members

Adding team member had: Positive results Negative results

TEAM MEMBERNUMBER OF STUDIES OUTCOMES

Care Manager (Nurses, Health technicians)

2 Short term costs increased with team-based care, but could lower overall long term costs, given quality outcome benefits .55 Improved LDL control and increase rate of aspirin use in coronary heart disease patients, significant improvement in blood pressure control .62

Pharmacist 2 No improvement in BP or DM control compared to control,54 Decrease in readmission rates .53**

Community Based (Community agencies, Community Health Workers, Health Coaches)

2 Improvement in DM control, access (small sample size) .59 19 .0% reduction in emergency department use and a 34 .7% reduction in hospitalizations .56

Behavioral Health Specialist or Training*

2 Improvement in depression treatment response when patients saw MHP .53 Lower overall payment, higher screening of depression,lower rates of ED and ACSH .61

Not specified 1 Team based care to improve blood pressure control is cost effective .57

* One study trained all team members in mental health concepts without incorporating a mental health specialist .

** Significant for face to face pharmacist visits vs control . Not significant for telephone visits with pharmacist vs control


on preventative services for the first 14 months of life.44 For the eight studies that utilized survey data, all outcomes were patient or parent (for pediatric patients) reported, having its own inherent limitations. Overall, there were mixed outcomes, but a trend toward positive. Three studies looked at quality differences for patients in PCMH labeled clinics versus patients with a usual source of care not in a PCMH. They demonstrated that there were limited differences in PCMH-type care versus usual source of care quality outcomes, especially within the studies utilizing MEPS data.37,42,43 These studies suggest that having a consistent clinic (usual source of care) may be one of the most impactful features of the PCMH. One study negatively correlated PCMH to screening (limited to only breast cancer patients; not a survey).45 Eight of the studies showed improvement in at least one of the quality outcomes assessed. 36,37,42,43,44,47,48,51 A study in the safety-net showed no correlation between PCMH-type care and quality outcomes.39


As mentioned previously, most of the PCMH enhancement studies measured the inclusion of additional team members on quality. Of the studies that reported on quality, three showed improvements in process measures,55,60,62 including LDL control,55 hypertension control,62 depression screening54 and use of the patient portal.60 Two studies showed mixed results, with some process measures improving and others getting worse.57,61 In one study, the addition of a team pharmacist actually resulted in longer median time to achieve blood pressure control.52 Three studies in this group looked at patient satisfaction and they all showed that adding an additional team member increased patient reported satisfaction scores.38,55,57

Differences in Utilization

Take home: Overall, data on utilization of services is mixed, but trends towards positive findings . Studies tend to show an increase

in PCP use but the data is inconsistent on whether this increase in PCP use leads to a concomitant change in specialty services, ER utilization, or hospitalizations .


Of the 17 PCMH implementation articles, 11 reported on utilization.21,22,25,20,28,29,30,31,32,33,27 All but one of the studies reported on ED utilization, the outlier focusing solely on PCP utilization.27 Hospitalizations28,32,20,21,33,29,25,22 and PCP or general outpatient visits20,21,22,25,27,28,31 were each reported in eight studies. Three studies included utilization metrics for only pharmacy data28,29,32 and two included only hospital readmission data.22,20

Overall, studies published in the past year generally revealed favorable associations between transformation and utilization outcomes. Studies generally looked at PCP visits, ED visits and hospitalizations. In terms of outpatient visits, six studies showed an increase in primary care and/or outpatient visits,20,22,27,28,29,32 while two studies found no significant difference in the number of outpatient visits.21,25 An increase in outpatient visits would suggest more appropriate utilization of the healthcare system if it led to less ED visits or hospitalizations. Yet the two studies that looked at PCP use and ED use came to different conclusions.20,22 While Chu et al. reported increased PCP visits and decreased ED visits in its article,20 Kern et al. reported increased PCP visits and increased ED visits,22 suggesting that evaluating PCP visits alone does not account for frequency of ED visits. In terms of ED use, two studies reported an increase,22,31 whereas five studies reported a decrease in utilization,20,25,29,30,33

suggesting an overall positive impact of PCMH on appropriate ED utilization (Appendix 1.2).

Patient-centeredness and having more coordinated care might help reduce readmission and ED use, especially in more vulnerable populations, and both are core components of the joint principles of the PCMH.


Although the studies on PCP and ED use suggest a positive impact of PCMH on utilization, the studies that looked at hospitalization were less clear. While a study of the Pennsylvania PCMH Medicaid initiative29 demonstrated a decrease in inpatient hospitalizations for patients with comorbid medical and psychiatric conditions, no other studies found any significant impact of PCMH transformation on hospitalization.20,21,22,25,28,32,33 One of the NCQA PCMH initiatives notably found no statistically significant outcomes for any of the six utilization metrics measured21 (Appendices 1.1 and 1.2).

Two of the reviewed reports are notable for their ability to offer insight into the impact of transformation stage on various utilization outcomes.32,33 Carlin et al. separated its analyses into categories—early, intermediate or late stage transformation, analyzing the effects of each stage on five domains: health care organization, delivery system redesign, clinical information systems, self-management support and

decision support. This demonstrated some evidence that later stage transformation contributed to fewer outpatient visits for diabetics and patients with cardiovascular disease, though results were not consistently positive. Furthermore, there were fewer outpatient visits overall, but that didn’t correspond to statistically significant differences in inpatient admissions or ED visits. The report also tried to explore the impact of the five domains individually on utilization outcomes with mixed or inconsistent results.32 Hearld et al. reviewed PCMH capacity, which was defined in 12 domains separated into two capacities (interpersonal and technical), and demonstrated that technical capacity had a greater impact on utilization than interpersonal, and time since transformation was the most significant variable on ED utilization.33 Although these two studies attempt to understand the characteristics of a PCMH that contribute to more appropriate utilization, more studies or a longer study period are needed before any consistent patterns can be identified.

FIGURE 6

Program Spotlight: PACT Enhancements

Positive results Mixed results Negative results

PROGRAM NAME INTERVENTION UTILIZATION COST QUALITY

H-PACT vs PACT Increased access to care with open-access, walk-in capacity, flexible scheduling, outreach to homeless veterans, on site community programs (food, hygiene), intensive health care management with care managers

Higher utilization of outpatient services, 19% reduction in ED visits and 34 .7% reduction in hospitalizations pre/post intervention

Im-PACT vs PACT Intensive outpatient program: multidisciplinary team, comprehensive patient assessment, tracking of patient goals, care management, frequent contact, community interventions, weekly team discussions of high risk patient

Increased PCP visits . No change in inpatient or ED utilization

Significant increase in monthly person-level primary care cost

No significant difference in mortality

Increased patient satisfaction

EQBI-PACT vs PACT Evidence based quality improvement EBQI-PACT had decreases mean primary care encounters and increases in mean telephone care encounters

No difference EBQI-PACT had higher use of secure messaging and higher rates of contact after discharge compared to PACT-only sites

artnering with veterans

ccess to care

oordinated care

eam-based careP A C T



Seven of the 15 articles examining features of PCMH care delivery reported on utilization. Four articles reported on ED visits,42,46,47,49 three of which also evaluated outpatient visits and hospitalization,46,47,49

three reported on readmissions,38,49,50 and one on use of mental health services.40 Compared with the PCMH implementation studies, there were mixed and primarily neutral impacts of PCMH type care on utilization. In studies where there were significant positive findings on utilization, there was no consensus as to which PCMH-like feature was most important in achieving these outcomes. A study in pediatric patients showed that PCMH did not impact readmission or ED visits, but usual source of care did,38 suggesting that having consistent care was more meaningful than the added benefit of other features of the PCMH. Additionally, in another study, separating by individual factors of a PCMH, having access to a usual source of care and insurance status were the only two reported characteristics that were associated with a lower likelihood of ED visits.42

Two studies showed an increase in PCP visits with PCMH-like interventions,46,47 yet it is unclear if higher PCP visits necessarily meant more appropriate utilization of care. In the Kohler et al. article that demonstrated higher PCP visits, there were also higher specialty visits without any impact on hospitalization or ED use.46 Druss et al. also shows higher PCP utilization with concomitant increase in appropriate preventive service use, but no difference in other utilization markers including mental health visits, ED visits or hospitalizations.47

The Garrison et al. study was unique in evaluating the impact of “visit entropy”—a marker of disorganized primary care delivery—and hospital readmissions.50

This study showed that more disorganized care, and thus less PCMH-type care, led to higher odds of readmission within a PCMH highlighting the importance of consistent primary care provider visits. The definition, and best metric, of coordinated care within the evolving model of team-based

care remains debatable. One study of a high-needs Medicaid population showed a reduction in ED visits without impact on hospitalizations or readmission.49

In reviewing the studies on features of PCMH care delivery, it is important to keep in mind that patient reported data was used in eight of the 15 studies, and accounting for three of the seven articles evaluating utilization. Given that there was little to no consistency in terms of insurance type, setting or survey data used, it is difficult to comment on the potential impact of individual factors across studies. Most of the studies, as noted above, showed little change or value over having a usual source of care. Patient-centeredness and having more coordinated care might help reduce readmission and ED use, especially in more vulnerable populations, and both are core components of the joint principles of the PCMH.


A majority of the PCMH enhancement studies focused on the impact of teams and team members on clinical outcomes. As with the PCMH implementation and features of PCMH care delivery studies, there were mixed utilization outcomes with a trend toward positive. Two team-based care interventions within NCQA PCMHs and one IT program in a VA-PACT reported a decrease in overall utilization in all of their study measures, correlating with the lower revenue and lower overall costs for the same studies noted above.54,59,60 A team-based care study targeting homeless veterans reported increased utilization of outpatient services and a corresponding drop in ED visits and hospitalizations.55 Another NCQA PCMH team-based care study noted lower readmissions with a pharmacy intervention, though not statistically significant.52 The Emerson et al. study focused on piloting a virtual visit program within a PCMH model serving uninsured patients, demonstrating feasibility of the program and willingness of patients to utilize alternative visit models, but not reporting on typical utilization outcomes.58


GREY LITERATURE: CENTERS FOR MEDICARE AND MEDICAID SERVICES INITIATIVE REPORTS AND STATE EVALUATIONS

The Centers for Medicare and Medicaid Services (CMS), along with individual states, have attempted to transform practices by supporting PCMH-type activities. Two such initiatives, the Comprehensive Primary Care Initiative (CPCI) and the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration have shown mixed results in utilization, cost and quality outcomes.

Comprehensive Primary Care Initiative (CPCI)

CPCI was a collaboration between CMS and other public and private payers who provided financial resources, learning support and data feedback to practices in select regions to improve primary care delivery with the goal of achieving better care, smarter spending and healthier

people.1 CPC practices received enhanced payments in the form of care management fees which, for Medicare fee-for-service (FFS) patients, totaled $15 per beneficiary per month (PBPM) in 2015. This translated to about 12.5% of 2015 total practice revenue for CPC practices. Despite this support, outcomes were less substantial than anticipated. CPC did reduce ED visits and hospitalizations for Medicare FFS beneficiaries as compared to non-CPC practices, but only the effects on ED visits were statistically significant.63 Furthermore, despite some improvements in utilizations, net cost to the system did not improve. Although the average PBPM Medicare expenditures increased by $9 less for the CPC-attributed patients, this did not cover the care management fees of $15 PBPM that were paid for Medicare FFS beneficiaries.63 In terms of quality of care provided, results were also mixed. There were some improvements in diabetes quality of care measures among high-risk beneficiaries with diabetes and a small reduction on the likelihood of an ED revisit within 30 days. All other measures studied were equivalent

FIGURE 7

CPCI and CPC+ Regions

CPCI Regions CPC+ Regions

New York–Hudson Valley

Ohio and Kentucky Ohio and Northern KentuckyGreater Kansas

Region spans the entire state

Region spans contiguous counties

Region spans the entire state

Round 2

Region spans contiguous counties

Greater Philadelphia

North Hudson–Capital Region

Greater Buffalo

Findings from 2012 to 2015 indicate that CPC practices greatest improvements are related to risk-stratified care management, access to care, and continuity of care. However, there continues to be room for improvement.

Peikes D, Anglin G, Taylor EF, Dale S, O’Malley A, et al . Evaluation of the Comprehensive Primary Care Initiative: Third Annual Report . Mathematica Policy Research . December 2016


between the two groups.65 It is important to note that the reported CPC findings are a roll-up of seven different regions into national results, yet state specific findings, as reviewed below, are more favorable.

Findings of State Reports within CPCI

The Accountable Care Collaborative (ACC) was launched in 2011 with the stated goal of improving the health of Medicaid members in Colorado by creating seven regional care collaborative organizations (RCCO’s) that are responsible for coordinating patient care and connecting members with non-medical services. Primary care medical providers (PCMPs) contract with RCCOs to become medical homes for Medicaid members in the collaborative. These RCCOs and PCMPs in return receive incentive payments based on their performance on key metrics. It is important to note that the ACC was a subset of programs in Colorado that participated in CPC.8

In Oregon, a similar program called the Patient Centered Primary Care Home (PCPCH) developed in 2009, taking the concepts of the medical home and applying them to primary care clinics throughout the state. The PCPCH provided support for practice transformation, identified and disseminated best practices of a medical home and encouraged individuals covered by Oregon’s Health Plan to enroll in PCPCH clinics.66 As with Colorado’s CPC program, not all CPC sites were PCPCH clinics.

Differences in Cost

Independent state evaluations of programs that participated in CPC, the ACC in Colorado and the PCPCH program in Oregon, have shown cost savings to different degrees.8,64 Over the time period of July 2009 through July 2015, the ACC was shown to save about $60 per member per month (PMPM) on adults and $20 PMPM on children as compared to eligible members who were not enrolled in an ACC

over the same time period.8 In dual eligible beneficiaries, this cost savings was about $120 PMPM.8 The independent evaluators note that grant funding and CMMI initiatives also contributed to declines in spending, yet even when controlling for this, there was still a demonstrated cost savings.8

In terms of cost, Oregon’s PCPCH also succeeded. Overall, the program reduced total service expenditures per person by 4.2%, or approximately $41 per person per quarter.64 Interestingly, as cost decreased, total service use increased, thus the total service expenditure is likely an underestimate of total savings to the program.64

Program NameAccountable Care Collaborative

Program Description1) Created seven regional care collaborative organizations (RCCO’s) that are responsible for coordinating patient care and connecting members with non-medical services; 2) Primary care medical providers (PCMPs) contract with RCCO’s to become medical homes for Medicaid members in the collaborative; 3) RCCOS’s and PCMP’s receive incentive payments based on performance on key metrics

Payment for ProgramsCPCI funding, Medicaid and Grant funding

Program OutcomesCost: Reduced costs about $60 per member per month (PMPM) on adults and $20 PMPM on children as compared to eligible members who were not enrolled in an ACC over the same time period . In dual eligible beneficiaries this cost savings was about $120 PMPM . *

Utilization: Well child checks for children ages 3-9 increased from 20 .6% for clients who were enrolled less than 6 months to 43% for those enrolled for 7 months or more . They also found that follow up care after hospital discharge increased from 41 .2% to 49 .4% the longer the patient was enrolled in the program . As time enrolled in the program increased, utilization of ER services decreased by 5% and 30 day all-cause readmissions decreased . **

Quality: No difference in key performance indicators

* Cost savings even shown when controlling for CPCI and grant funding** Significance testing not done or not reported

FIGURE 8

STATE SPOTLIGHT

Colorado


FIGURE 9

Program Spotlight: CPCI

Description of Intervention

Launched by CMMI in October 2012 as a method to improve primary care delivery and achieve better care . Designed as a multi-payer collaboration along the five key delivery functions below . Under each key delivery function there are milestones for 2015 .

Access and continuity• Enhance patient’s ability to

communicate with care team 24/7• Implement asynchronous forms of

communication (patient portal)• Empanelment

Planned care for chronic conditions and preventive care• Continue to perform QI using EHR-

based quality measures• Review at least one payer data

feedback report to identify a high-cost area and a strategy to reduce costs

• Participate in learning collaboratives

Risk-stratified care management*• Behavioral health integration• Medication management• Self-management support

Patient and caregiver engagement• Assess patient experience

through surveys• Shared decision making using at

least three decision aids

Coordination of care across the medical neighborhood*• Follow up with patients within one

week of ED visit• Contact at least 7% of hospitalized

patients within 72 hours of discharge

• Enact care compacts with at least two groups of high volume specialists

* Practices were expected to use one of the three methods listed to meet the key delivery function

Program Participation

Year 1 (2013) Year 2 (2014) Year 3 (2015)

Number of Participating Payers (Baseline 39)

37 37 36

Number of Participating Practices (Baseline 502)

492 479 445*

Financial Support (median per practice)

$227,800 $203,900 $175,775

Identified Success and Challenges of Year 3

Successes Challenges

• Peer-to-Peer Learning• Utilization of data for feedback• Small tests of change• Risk stratification

• Burden of quality reporting• Adverse incentives of FFS payment• Lack of comprehensive and efficient

health information exchange

Outcomes

Cost (With care management fees)

Decreased by 2%*** Decreased by 1%No net savings . Increased cost in Ohio/Kentucky**

Utilization

ED Decreased by 1% Decreased by 1% Decreased by 2%***

Hospitalizations Decreased by 2% Decreased by 2% Decreased by 1%

Quality (Urine protein testing in diabetics)****

Increase by 0 .7% Increase by 1 .6%*** Decrease by 0 .1%

* Most of the practices that left voluntarily withdrew to join Medicare ACOs . ** Shared-savings calculations (different than the evaluation) showed savings in Arkansas, Colorado,

Oklahoma and Oregon . *** Statistically significant result . All other reported results not statistically significant to P values < 0 .05% .**** Among quality of care process measures urine protein testing in diabetics was the only measure that

showed a statistically significant change .



The state evaluations reviewed were much less focused on quality measures than the peer-reviewed literature, and when quality was mentioned, it was done mostly via qualitative methods, making direct comparisons to non-medical home models less clear. The Colorado program did complete a quantitative study on the ACC’s effect on Key Performance Indicators (KPI’s), and found no difference in KPI’s between ACC and fee for service (control) patients.8

Given that there was no change in KPI’s, yet the program did see more appropriate utilization and decreased cost, it concluded that reduced spending in the program was done while keeping quality of care constant.8


The findings for utilization in the state initiatives published this year trended towards positive findings as well, though not all results showed statistical significance. In Oregon, the PCPCH program resulted in an increase in primary care and pharmacy services, and a reduction in all other service types. Of these, only total, specialty and inpatient care decreases were statistically significant.64 An increase in primary care, and as a result pharmacy services, as was seen in Oregon, is generally looked upon as favorable especially if it is associated with a decrease in ER visits and inpatient hospitalizations. Interestingly, mental health care usage, generally looked upon as a favorable use of healthcare resources, decreased.64 The thought behind this finding is that primary care providers were likely treating patients with less serious mental health conditions, though there was no direct data to demonstrate this.

In Colorado, the results on utilization were also positive. Utilization results were expressed as increase or decrease in use over time of enrollment in the ACC. In other words, there was no direct comparison to similar patients not enrolled in the ACC. The program took this approach because,

at the time of analysis, more than 70% of Medicaid clients in Colorado were enrolled in the ACC and the groups who were not enrolled differed significantly in medical comorbidities.8 Using this approach, evaluators of the program found that well child checks for children ages three to nine increased from 20.6% for clients who were enrolled less than six months, to 43% for those enrolled for seven months or more. The evaluators also found that follow-up care after hospital discharge increased from 41.2% to 49.4% the longer the patient was enrolled in the program. As time enrolled in the program increased, utilization of ER services decreased by 5% and 30 day, all-cause readmissions decreased.8 A few limitations exist for this data. First, it is unclear which, if any, of these results show

“One of the most important takeaways from CPC is showing the benefit and critical importance of aligning efforts across all of the payers in a region.”

–Russell Kohl, MD, FAAFP

Program NameHealth Care Home Initiatives (HCHI)

Program Description1) Provided financial incentives for clinics to transform; 2) Developed a learning collaborative for participating clinics; 3) Developed certification standards and transformation assistance

Payment for ProgramMAPCP

Program OutcomesCost: Demonstrated significant savings on their Medicare, Medicaid and Dual eligible beneficiaries as compared to non-health care home patients in the same time period

Utilization: 1) Increase in emergency department and skilled nursing home use relative to non-Health Care Homes; 2) Significant decreases in the use of inpatient hospital services; 3) Slight decrease in the use of prescription drugs . 3) Decreased hospital based outpatient visits;* 4) Increase in office based outpatient visits

Quality: 1) Better adjusted quality of care for patients with diabetes, lipid screening, asthma, depression and colorectal cancer screening; 2) Largest and most significant findings were in optimal asthma care; 3) Patient experience was unchanged

* Generally more expensive visits and usually comprise of specialty visits rather than primary care visits .

FIGURE 10

STATE SPOTLIGHT

Minnesota


statistical significance, as this was not addressed in the methods. Second, although rates of well child visits increased and ER utilization decreased, ACC client were still below the state benchmark on both of these measures. Finally, there was no mention of rates of primary care visits in general, or avoidable inpatient hospitalizations, making the data on more appropriate usage of care less transparent. Although it is unclear how significant these findings are, the ACC did show a trend in the right direction and there was an obvious benefit, in terms of utilization, to staying in the program for longer periods of time.

Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP)

Another CMS initiative aimed at practice transformation is the Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP), which started in 2011 and included joint CMS and state initiatives promoting the principles of PCMH in eight states.

Each state was limited to a $10 average PMPM payment, applied consistently by all participating payers, but each state had its own payment levels and established its own payment models. Some states paid practices differently based on their NCQA PCMH status, whereas others paid practices differently based on patient comorbidities. Each state had to integrate community-based resources along with its integration of PCMH practices; how they chose to do this was left up to the states.67

Data from the most recent, or third round, of site visits occurring in October and November of 2014 showed only thematic data when looking across states. Interviews conducted as part of the MAPCP initiative report showed that states felt that care management or care coordination seemingly had the most significant impact on utilization and expenditures. Identifying and reaching out to patients who were recently hospitalized, as well as risk stratifying and allocating resources to high utilizers, were the two care management activities that impacted utilization the most.65 This was also consistent with findings in the national CPC report.63 The MAPCP report conclusions were based on thematic analysis of interviews with states and were not based on quantitative data, so it remains unclear whether care management had an independent positive effect on cost and utilization or if respondents felt this way because it was the most “visible” component of the state wide initiatives.

State specific quantitative data on cost, utilization and quality were reported for certain states. In New York and Vermont, commercial payers and Medicaid reported reductions in admissions, readmissions and ER visits. Other states such as Michigan, North Carolina and Rhode Island reported difficulty in influencing utilization and expenditures.65 Only one state in the MAPCP, Minnesota, had a separate evaluation of quality, cost and utilization in its program.68

Transformed and transforming practices need time to mature before significant improvements can be achieved. When looking at Michigan, the largest and longest running PCMH demonstration project, it is clear that the PCMH does have a positive impact on healthcare.

Program NamePatient Centered Primary Care Home

Program Description1) Provide financial support for practice transformation; 2) Identify and disseminate best practices of a medical home; 3) Encourage individuals who are covered by Oregon’s Health Plan to enroll in PCPCH clinics

Payment for ProgramCPCI funding and Medicaid

Program OutcomesCost: Reduced total service expenditures per person by 4 .2%, approximately $41 per person per quarter

Utilization: Increase in primary care and pharmacy services, and a reduction in all other service types . Of these, only total, specialty and inpatient care decreases were statistically significant

Quality: Not mentioned

FIGURE 11

STATE SPOTLIGHT

Oregon


Findings of State Reports in the MAPCP

Differences in Cost

Between 2010 and 2014, HCHs demonstrated significant savings on their Medicare, Medicaid and dual eligible beneficiaries, as compared to non-HCH patients in the same time period, even after correcting for differences in patient populations.66


Minnesota conducted an independent evaluation of its MAPCP initiative, the Health Care Home (HCH) Initiative in 2016. In Minnesota, quality of care for HCH patients improved, showing better adjusted quality of care for patients with diabetes, lipid screening, asthma, depression and colorectal cancer screening. The largest and most significant findings were in optimal asthma care. Patient experience, on the other hand, was unchanged for HCH versus non-HCH clinics.66


In Minnesota, the HCH initiative also showed mixed results in utilization. HCHs actually saw an increase in ED and skilled nursing home use relative to non-HCHs. Yet, there were significant decreases in the use of inpatient hospital services. Interestingly, HCHs saw a slight decrease in the use of prescription drugs. The data also shows that hospital-based outpatient visits did decrease, whereas “professional encounters in a clinical setting,” or the correlate for office-based primary care visits, increased. The authors of the article viewed the decrease in hospital-based office visits as a positive given that these visits are generally more expensive, and usually comprise of specialty visits rather than primary care visits. Overall, the significant decreases in the use of inpatient hospital services was thought to be the primary driver for the cost savings noted above.66

[A] common lesson in all states was the need for ample time and resources to bring about practice transformation, including adequate resources for program administration and oversight. Across states and stakeholder groups, many interviewees believed that 3 years was not enough time for the MAPCP Demonstration to show positive results.

RTI (Research Triangle Institute) International . Measurement, Monitoring, and Evaluation of the Financial Alignment Initiative for Medicare-Medicaid Enrollees; Evaluation of the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration: Third Annual Report . April 2016 .


Discussion

STUDY RESULTS

The review of current evidence for primary care practice transformation trends in addressing cost reductions, quality and utilization of care shows that the PCMH continues to have an impact in the way primary care is delivered. Several gains have been made although not uniformly.

In general, when looking at cost, peer-

reviewed studies showed a positive

impact, though not always with statistical

significance. In addition, results on quality

in the peer-reviewed literature showed

either a trend towards positive results or no

change in quality. Only a few of the positive results were statistically significant, and quality measures were not harmonized between studies. The limited studies that

did comment on patient satisfaction were

uniformly positive. Finally, in terms of

utilization, peer-reviewed literature showed

mixed results. Although there seemed to be increases uniformly in outpatient PCP visits, this wasn’t always correlated with decreases in ER admissions or inpatient admissions. The studies that looked at both cost and utilization showed that more appropriate utilization of services led to cost savings.

Evaluation reports of two large Medicare Initiatives showed mixed63 or no65 results on cost. In the CPCI, while cost savings were seen overall, the savings did not offset the payments made to the programs by Medicare. Nonetheless, when evaluating programs such as CPCI, it is important to consider that overall value is comprised of cost, quality and utilization and not one element in isolation. Given that CPCI

demonstrated some positive effects to

utilization and quality without any negative

outcomes, one could argue that although

they were no net-cost savings to the system

as whole, the programs were spending

smarter. Furthermore, state specific reports

of CPCI and MAPCP regions generally

showed more favorable results in terms of cost, quality and utilization, demonstrating that regional and program-specific differences contribute to the success of a PCMH and should be further studied in an attempt to understand best-practices of primary care transformation.

LIMITATIONS

A few limitations emerged in this review, both in the data and in the compilation of this report. Because of the heterogeneity of study design and outcome measurement, it was difficult to draw quantitative conclusions about cost, utilization or quality. Instead, we relied on a more thematic analysis, and reported general trends when analyzing the studies as a whole. Our comprehensive tables (Appendices 1.1 and 1.2), which include more quantitative data, as well as commentary on study quality and design, help to explain our conclusions, and were reviewed by two independent authors to help minimize bias.

In terms of limitations of the studies

themselves, many were conducted over

short periods, often one to two years

after transformation, and had limited

numbers of participants, and at times lack

of controls. Assuming that practices at a

more mature stage of transformation have

better established outcomes, the short time

span of the analysis may explain why many

studies had mixed, neutral or non-significant

results. Furthermore, supposing that practice transformation is most successful in high-risk patient populations, those


studies that focused on smaller populations of patients, or those in a less high-risk pool, may have had negatively skewed or neutral results. In fact, it has previously been reported that most studies on the PCMH are underpowered due to the small populations studied, resulting in a lack of significant findings.69 Much of the data reported over the past 14 months was outdated, and assuming that PCMHs continue to learn and refine their practices, we may be underestimating the true current effect of practice transformation on the healthcare system. Yet, this is less of a flaw in our study design and more a commentary on the time and resources it takes to get studies ready for publication in peer-reviewed journals.

Finally, provider satisfaction was not studied in this report. As we move towards a healthcare system that strives to achieve the Quadruple Aim, we must try to understand the impact of practice transformation on the provider, and future iterations of this report should consider this.

LESSONS LEARNED

Despite these limitations and, in general, mixed or non-significant findings, there are some lessons to be learned. First,

patients with greater comorbidity and

systems with these patients may show

greater early strides in improved outcomes

with the PCMH. For example, although nationwide analysis of two Medicare Incentive Programs, CPCI and MAPCP, showed mixed findings, state specific reports, which focused on the Medicaid subgroups of these initiatives, were more favorable. Assuming Medicaid beneficiaries in these states have more previously unfilled healthcare needs than the average population, there are greater gains to be made in quality, cost and utilization. The peer-reviewed literature also supported this finding in that the studies that reported uniformly positive results for

quality, cost and utilization were focused on patients in a safety-net or community health center setting. Yet, results aren’t always positive for patients with higher comorbidity and previous literature has argued that the PCMH can worsen disparities if not all patients have access to the same quality of care.70,71

Second, transformed and transforming

practices need time to mature before

significant improvements can be achieved.

Whereas the CPC and MAPCP reports included analysis of three years of data, the state reports looked at four to six years of data. The peer-reviewed findings this year

also supported this claim in that a majority

of the studies that looked at four years or

more of data had positive results,27,29,33,37,49,54,60,62 whereas many of the studies looking at two years of data or less had mixed or non-significant results.20,21,32,31,45,38,42,50 Furthermore, when looking at Michigan, the largest and longest running PCMH demonstration project, it is clear that the PCMH does have a positive impact on healthcare.2,11,12,13,14,15 This data suggests that the longer a practice has been transformed, the more positive its impact on quality, cost and utilization. Policy makers should realize that not supporting initiatives that show mixed or slightly negative results before they have had time to mature could be detrimental to the implementation and spread of positive ideas. In fact, despite the lack of statistically significant gains nationwide in CPCI, CMS and private payers were impressed enough with the first three years of findings to continue to expand the program into 14 regions. This new program, CPC+, aims to take lessons learned and best practices from CPCI and apply them to transforming more than 2,800 primary care practices.

Third, mixed results in the grey literature

and peer-reviewed literature further the

notion that we can’t apply a one-size-

fits-all approach to the implementation

and evaluation of practice transformation.

As PCMH’s proliferate it becomes hard for non-transformed practices to become totally immune to the uptake of PCMH concepts, thereby dampening the results of studies that attempted to look at “control” populations.


Regional differences in patient demographics as well as site-specific differences in implementation of the PCMH model likely contribute to mixed results. Two studies this year attempted to pinpoint the most successful characteristics of a PCMH, but were unsuccessful in doing so.32,33 Michigan’s successful experience of using lessons learned from transformed practices as a blueprint for their own practice transformation (Figure 1)72 suggests that the framework for implementation is more important than any one specific feature of a PCMH, and future studies should evaluate the impact of different frameworks for implementation.

Finally, the mixed results seen in this

review may be due to a positive spill-

over effect of transformed practices on

practices that have yet to transform.

We are 10 years out from the creation of the “Joint Principles of the Patient Centered Medical Home,” and practice transformation has been widely implemented.9,73 As PCMH’s proliferate it becomes hard for non-transformed practices to become totally immune to the uptake of PCMH concepts, thereby dampening the results of studies that attempted to look at “control” populations.

IMPLICATIONS FOR THE FUTURE

Almost all of the authors of the 45 peer-reviewed studies, and five CMS and state reports, called for further analysis of contributing factors of PCMH care delivery, and longer-term follow-up. The authors are likely correct that it is difficult for care delivery to change over a few years, and continued in-depth analysis as we make our way toward optimized care delivery is vital to inform progress along the way. Judging by the success of practice transformation in Michigan, the longest running and largest PCMH demonstration project to date, as well as the successes of CPCI and MAPCP regions this year such as Oregon, Colorado and Minnesota, the PCMH concept has the potential to make great strides towards accomplishing the Quadruple Aim. With MACRA and a changing political climate upon us, it is more important than ever to understand how programs like Michigan achieved success and which payment models best support these functions. Continued efforts to study transformed practices, especially those that have reached a state of maturity, will help guide successful innovation and payment, and help demonstrate the need for a continued investment in access to high-performing primary care, the definition of which is embodied in the soon to be released 2017 Shared Principles.


1 . American Academy of Family Physicians . Joint Principles of the Patient-Centered Medical Home, March 2007 http://www .aafp .org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint .pdf

2 . Blue Cross Blue Shield of Michigan . http://www .bcbsm .com/content/dam/public/Providers/Documents/help/documents-forms/partners-report .pdf

3 . Starfield, B ., Shi, L . and Macinko, J . (2005), Contribution of Primary Care to Health Systems and Health . Milbank Quarterly, 83: 457–502 . doi:10 .1111/j .1468-0009 .2005 .00409 .

4 . Maeng DD, Davis DE, Tomcavage J, Graf TR, Procopio KM . Improving Patient Experience by Transforming Primary Care: Evidence from Geisinger’s Patient-Centered Medical Homes . Population Health Management . 2013;16(3):157-163 . doi:10 .1089/pop .2012 .0048 .

5 . Phillips RL, Bronnikov S, Petterson S, et al . Case Study of a Primary Care-Based Accountable Care System Approach to Medical Home Transformation . Journal of Ambulatory Care Management . 2011;34(1):67-77 . doi:10 .1097/jac .0b013e3181ffc342 .

6 . Roland M, Guthrie B, Thome´ DC . Primary medical care in the United Kingdom . J Am Board Fam Med 2012;25(Suppl):S6 –S11 . 2 .

7 . van Weel C, Schers H, Timmermans A . Health care in The Netherlands . J Am Board Fam Med 2012;25(Suppl):S12–S17

8 . Colorado Department of Health Care Policy and Financing: Supporting a Culture of Change: Accountable Care Collaborative 2015 Annual Report .

9 . Adams J, Grundy P, Kohn M and Mounib E . PCMH, what, why and how? IBM Global Business Services Report .

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21 . Flieger SP . Impact of a Patient-Centered Medical Home Pilot on Utilization, Quality, and Costs and Variation in Medical Homeness . Journal of Ambulatory Care Management . November 2016:1 . doi:10 .1097/jac .0000000000000162 .

22 . Kern LM, Edwards A, Kaushal R . The Patient-Centered Medical Home and Associations With Health Care Quality and Utilization: A 5-Year Cohort Study . Ann Intern Med . 2016;164:395-405 . doi: 10 .7326/M14-2633 .

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54 . Price-Haywood EG, Dunn-Lombard D, Harden-Barrios J, Lefante JJ . Collaborative Depression Care in a Safety Net Medical Home: Facilitators and Barriers to Quality Improvement . Population Health Management . 2016;19(1):46-55 . doi:10 .1089/pop .2015 .0016 .

55 . Kottke TE, Maciosek MV, Huebsch JA, et al . The Financial Impact of Team-Based Care on Primary Care . American Journal of Managed Care . 2016;22(8):232-286 .

56 . O’Toole TP, Johnson EE, Aiello R, Kane V, Pape L . Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program . Preventing Chronic Disease . 2016 . doi:10 .5888/pcd13 .150567 .

57 . Zulman DM, Chee CP, Ezeji-Okoye SC, et al . Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial . JAMA Internal Medicine . 2016;177

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68 . Peikes D, Dale S, Lundquist E, Genevro J, Meyers D . Building the evidence base for the medical home: what sample and sample size do studies need? White Paper (Prepared by Mathematica Policy Research under Contract No . HHSA290200900019I TO2) . AHRQ Publication No . 11-0100-EF . Rockville, MD: Agency for Healthcare Research and Quality . October 2011

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71 . “Primary Care Transformation: Ten Lessons for the Path Forward .” Interview by Lisa Watkins, Patrick Gordon, Lisa Leternoux, and Jenney Samuelson . Millbank Memorial Fund Issue Brief June 2015 .

72 . AAFP 2015 Practice Profile . dated July 15, 2016 by AAFP Marketing Research

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The patient-centered medical home is not a pill. It would be much easier to evaluate this primary care reform if it were. Grumbach, Kevin (2013) . JAMA Internal Medicine . The Patient-Centered Medical Home Is Not a Pill: Implications for Evaluating Primary Care Reforms . 173 . 20 . 1913-1914 .

Appendix

Study/Reference Year Payment Model Impact on CostImpact on Utilization

Impact on QualityPCP ED IP

Rosenthal, et al .25 2007–2011Multi-payer; financial incentive

Positive * Positive Positive

Flieger SP21 2011 Multi-payer Negative Mixed or Equivocal

Mixed or Equivocal

Kern LM, et al .22 2008–2012Multi-payer; financial incentive

Positive Negative Positive Mixed or Equivocal

Chu, et al .20 2011–2013Managed Medicaid plan

Positive PositiveMixed or Equivocal

Shi L, et al .26 2012 Mix Positive

Khanna N, et al .23 2011–2013Maryland multi-payer

Positive

Lauffenburger, et al .24 2011–2013 Aetna Positive

Baughman AW, et al .45 2012–2013 Multi-payer Negative

Bronstein JM, et al .28 2010–2013 Medicaid patients Mixed or Equivocal Positive

Rhodes KV, et al .29 1/2005–6/2010 Medicaid patients Positive Positive Positive

Shane DM, et al .30 1/2011–12/2013 Medicaid Positive Positive

Carlin CS, et al .32 2010 Multi-payer Positive

Glover CM, et al .31 2013 Medicaid Negative

Cuellar A, et al .34 2010–2013 Financial incentive Positive

Maeng DD, et al .36 2008–2013Geisinger health system

Positive

Hearld LR, et al .33 2008–2012 BCBS Michigan . Positive Positive Mixed

Wong ES, et al .27 2003–2013 VA Positive

Kohler RE, et al . 2003–2007 Medicaid Negative Positive

Bitton A, et al .37 2009 Multi-payer Positive

Reibling N .43 2010 Multi-payer Positive Positive

Coller RJ, et al .39 2012–2014 Multi-payer Mixed or Equivocal

Mixed or Equivocal

King J, et al .42 2012 Multi-payer Positive

VanGompel EC44 2007–2010 Positive

Key* Not statistically significantPC : Primary Care VisitsED: Emergency Room VisitsInpatient Hospitalizations: for any causePositive utilization: Increased PCP visits, decrease ED visits, decreased inpatient stays

APPENDIX 1.1

Overview of Peer Reviewed Studies: PCMH Transformation/PCMH-Like Transformation


PCMH Intervention


Participant or Population: 17 studies; 8-9 regional (5 NCQA, 2 safety-net, 1 PACT); 5 state-based (4 Medicaid, 1 multi-payer); 4 insurance (3 BCBS, 1 other commercial)Settings: multi-state, regional, state-based AND insurance based

Intervention: PCMH transformationComparison: Traditional care in 7 regional/4 state-based; pre/post only Wong (regional); Stage transformation Carlin (state); Various metrics PCMH exposure/capacity for 4 insurance studies

Outcomes Impacts Quality of Evidence

Cost7 studies

Overall: Positive

• 2 increased costs (1 NCQA, 1 Medicaid)• 5 cost savings• 1 savings only if chronic and mental health conditions

(Alabama Medicaid)• Increased savings over time/and with chronic conditions

• Flieger: Appear well-matched• Rosenthal: PCMH had higher screen rate at baseline• Bronstein: Pilot areas more urban, larger panel sizes• Rhodes: Well matched comparison group• Shane: Well matched• Cuellar: Spending lower at baseline; drug spending was higher

but ED and inpatient care costs were lower at baseline in always PCMH group

• Maeng: No control group

Utilization11 studies

Overall: Mixed or Equivocal

• 1 NCQA with no statistically significant findings in utilization• 2 with increased PCP visits (Alabama Medicaid, PACT

[only if >65])• 1 non significant decrease ED visits (NCQA) • 2 increased ED (NCQA &Medicaid)• 5 decrease ED visits (1 NCQA, 1 safety-net, 2 Medicaid,

1 BCBS)• 1 decrease inpatient hospitalization (Medicaid); otherwise

no significant changes in 10 of 11

• Kern: PCMH patient younger/healthier at baseline• Flieger: Appear well-matched• Rosenthal: PCMH had higher screen rate at baseline• Chu: PCMH clinics had lower ED visits at baseline, Medicaid

patient specific• Bronstein: Pilot areas more urban, larger panel sizes• Rhodes: Seemingly well matched comparison groups; focus was

on patients with co-morbid psych and/or substance use disorder• Shane: Medicaid patients; well matched• Carlin: Part survey data; no control• Glover: MHN patients more likley to have asthma and higher

acuity in ED but more likely to be discharged from ED• Hearld: Includes survey data; no control group; part of BCBS

payment reform• Wong: No control group

Quality7 studies

Overall: Mixed or Equivocal

• 1 study improved med adherence (NCQA)• 1 study improved 7-day discharge follow up (BCBS MI)• 2 studies with measures better than control, but screening

decreased over time • 3 with mixed improvements or lack of improvement

(2 NCQA, 1 safety-net)

• Kern: PCMH patients younger/healthier at baseline• Flieger: Appear well-matched• Rosenthal: PCMH had higher screening rates at baseline• Shi: PCMH clinics had ~2x revenue at baseline than control

clinics, less uninsured patients, more CHC/HCH funding . Lower clinical performance in PCMH may have been secondary to the way data pulled (use of EHRs to report clinical performance)—potential bias chart review

• Khanna: Self-reported quality metrics; pre/post, no control• Lauffenburger: Use NCQA roster 2014, but study dates 2011-13

APPENDIX 1.2

Summary of Outcomes


Interventions aimed at features of PCMH


Participant or Population: 15 studies; 2 Pediatrics (Coller & Samaan), 2 breast cancer patients only (Baughman, Kohler), 2 mental health focus (Druss & Jones), 1 payment/Canadian (Kiran), 2 safety-net (Druss, Gunter) Settings: 8 surveys (4 MEPS); all but 1 mixed insurance (1 with FFS vs . capitated-Kiran/Canadian); Kohler- NC medicaid; 2 safety-net

Dates: 2001-2014 (broad range), 1 not specified (Druss)Intervention: To evaluate the impact of features of PCMH without recognition of PCMH statusComparison: 10 with control groups (usual source of care), 1 pre/post only (Samaan), 1 compared clinic scores on SNMHI (index medical home characteristics), 2 regressions (Coller, Garrison [no control]), 1 transformation score (Baughman)


Cost1 study

Overall: Negative • Kohler: Only study breast cancer patients


Overall: Mixed or Equivocal impact

• PCP: 2 increased PCP visits (safety-net patients with mental health needs; NC Medicaid)

• ED: Patient-centeredness decreased ED visits (MEPS), decrease ED visits with care coordination for high-need Medicaid (Medicaid); no difference 1 (Kohler); 1 correlate visit entropy with more ED (Garrison)

• Inpatient: No differences 1 (Kohler); Garrison—entropy results in more hospitalizations

• Reibling: MEPS survey data; no composite of all PCMH factors• Coller: NSCSHN survey• Jones: MEPS survey—includes 2004 data (to 2011)• Kim: Unique program in each county; different funding per

county; intervention gap with more African American/less Hispanic, more existing physical health conditions, similar utilization

• Druss: Started at very different primary care utilization rates • Kohler: Only study breast cancer patients• Garrison: No control; readmission gap for older patients and

those with more comorbidity

Quality10 studies

Overall: Mixed or Equivocal but trend toward Positive

• 1 study negatively correlated PCMH to screening (limited to breast cancer patients)

• 2 showed no difference• 6 showed improvement in at least some screening• 1 showed little difference from just usual source of care

• Baughman: Only focus women with breast cancer; no control group

• Bitton: Survey data; different baseline sex/race/ethnicity/education/insurance/age

• Bowdoin: MEPS data; focus on adults with mental illness• Reibling: MEPS survey data; no composite of all PCMH factors• King: NAMCS survey data; data for all office based providers

except anesthesia/radiology/pathology)• Kiran: Canadian study• Samaan: No control; very targeted (pediatrics 0-14mo)• VanGompel: MEPS; PSA no longer recommended• Gunter: SNMHS data; safety-net specific• Druss: Started at very different primary care utilization rates


PCMH enhancement interventions


Participant or Population: 13 studies; 1 diabetic patients only (Eisenstat), 1 uninsured only (Emerson), 1 homeless VA (O’Toole), 1 high-utilizers VA (Zulman), 3 safety-net (non-VA) (Emerson, Price-Haywood) . 1 Medicare (Tedesco), 2 primarily publicly insured (Price-Haywood)Settings: 5 NCQA, 4 VA PACTDates: Primarily 2009-2014 (Emerson not specified; Reiss-Brannan 2003–2013)

Intervention: Enhancement projects within already established PCMH clinics . Team based care (TBC) 10, 2 pharmacy (Price-Haywood clinical pharm & Tedesco), 1 mental health (Price-Haywood) . 1 payment (Salzberg), 2 IT (Yoon, Emerson) 3 complex care management (Zulman, Kottke, O’Toole)Comparison: Control PCMH pts (8), pre/post only 4 (Eisenstat, Kottke, O’Toole); 1 payment FFS vs . capitated (Salzberg)


Cost5 studies

Overall: Positive

• 3 decreased costs• 2 unchanged costs (payment report and PACT TBC)

• Kottke: Pre/post implementation groups were not same people; no control group

• Reiss-Brennan: Unclear what level NCQA the control clinics were (presume not level III); p values for baseline characteristics not reported

• Salzberg: Well-matched• Zulman: Intervention group with statistically significant

higher levels dementia at baseline; only 69% engaged with program, and those who engaged were more likely to have non-VA health insurance; less Hep C/alcoholism than non-engaged intervention patients


Overall: Mixed, trend toward positive

• 3 increase service utilization (IT intervention, TBC/PACT, care management/PACT)

• 2 decreased overall utilization (TBC/NCQA, IT/PACT)• 2 decrease ED (TBC [1 in PACT] x2)• 2 decreased hospitalization (TBC/PACT)• 1 decrease ED but increase hospitalization

(payment reform study)

• Emerson: Small study population, only 14 total virtual visits, only 4 patients in each study arm completed study

• Kottke: Finance impact TBC: pre/post implementation groups were not same people; no control group

• O'Toole: Unable to account for non-VHA utilization• Reiss-Brennan: Unclear what level NCQA the control

clinics were (presume not level III); p values for baseline characteristics not reported —told no differences

• Salzberg: Well-matched• Tedesco: Compared 2 different clinics; intervention group had

better team based care to begin with (care manager); very small sample; patients who received face to face visits may have been healthier to start

• Yoon: VA patients only; longitudinal data comparing EBQI PACT and 28 comparison clinics pre/post PACT

Quality8 studies

Overall: Mixed, trend toward positive

• TBC improved diabetes mellitus (DM) control (in DM specific study)

• 1 Improved low density lipoprotein (LDL) control and appropriate aspirin use (NCQA)

• 1 improved blood pressure (bp) control (PACT) but less positive BP control in another (NCQA)

• Improved depression treatment response, higher overall prevention scores (NCQA)

• Care coordination improved communication/continuity but no mortality benefits (PACT)

• Eisenstat: Focused on DM patients only• Kottke: Pre/post implementation groups were not same

people; no control group• Kravetz: Seems well matched• Price-Haywood: Clinical pharmacy study: at baseline, group

in pharmacy intervention were higher risk, worse control HTN and DM, more co-morbidities; more baseline PCP visits

• Price-Haywood: Collaboration study: more patients who saw a mental health provider had insurance and saw their PCP twice as much; up to PCP whether to refer to mental health or complex care management

• Reiss-Brennan: Unclear what level NCQA the control clinics were (presume not level III); p values for baseline characteristics not reported

• Zulman: Intervention group with statistically significant higher levels dementia at baseline; only 69% engaged with program, and those who engaged were more likely to have non-VA health insurance; less Hep C/alcoholism than non-engaged intervention patients


State initiative reports


Participant or Population: 4 studies; 2 insurance mixed (OR, MN), 2 Medicaid (CO and OK); dates 2010–2014Settings: Colorado, Oklahoma, Oregon, Minnesota

Intervention: State-based PCMH interventionsComparison: Non-PCMH clinics vs . prior years


Cost4 studies

Overall: Positive

• (CO, OR, MN, OK), but some mixed results (MN had increased ED/ambulatory surgery costs; OR had increased individual costs for PCP visits, mental health, radiology/labs/pharmacy)

• Colorado: State reported; no p-values reported• Oklahoma: State reported; no p values, not great methods

section, hard to tell what's significant (excluded from narrative because of this)

• Oregon: State reported; p values comparing groups not listed; PCPCH group more Medicaid, younger, more behavioral health issues but overall less chronic disease

• Minnesota: State reported; per report “HCHs had younger patients, fewer female patients, and patients with lower disease burden, all of which should lower costs . But HCHs also saw more patients of color, which typically increases costs .”


Overall: Positive

• ED: 1 decrease ED (CO), 2 increase ED (MN, OK), 1 no change (OR)

• PCP: Increase PCP visits (OK, CO, OR)

See above

Quality3 studies

Overall: Positive See above


About the Patient-Centered Primary Care CollaborativeFounded in 2006, the Patient-Centered Primary Care Collaborative (PCPCC) is a not-for-profit multi-stakeholder membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home . Representing a broad group of public and private organizations, PCPCC’s mission is to unify and engage diverse stakeholders in promoting policies and sharing best practices that support growth of high-performing primary care and achieve the “Quadruple Aim”: better care, better health, lower costs, and greater joy for clinicians and staff in delivery of care .

PCPCC is and will position itself as an advocacy organization—a coalition that serves as a “driver of change,” educating and advocating for ideas, concepts, policies, and programs that advance the goals of high-performing primary care as the foundation of our health care system .

www.pcpcc.org

About the Robert Graham CenterThe Robert Graham Center aims to improve individual and population healthcare delivery through the generation or synthesis of evidence that brings a family medicine and primary care perspective to health policy deliberations from the local to international levels .

www.graham-center.org

About the Milbank Memorial FundThe Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience . Founded in 1905, the Fund engages in nonpartisan analysis, collaboration, and communication on significant issues in health policy . It does this work by publishing high-quality, evidence-based reports, books, and The Milbank Quarterly, a peer-reviewed journal of population health and health policy; convening state health policy decision makers on issues they identify as important to population health; and building communities of health policymakers to enhance their effectiveness .

www.milbank.org


AcknowledgmentsThis report would not have been possible without the support of Milbank Memorial Fund, the Robert Graham Center, IBM Watson Health, the authors and reviewers, as well as Grant Connor, Georgetown University Department of Family Medicine; and Katie Dayani, American Academy of Family Physicians .


PCPCC.ORG

601 Thirteenth Street, NW Suite 430 North Washington, DC 20005

GRAHAM-CENTER.ORG

1133 Connecticut Avenue, NWSuite 1100Washington, DC 20036

The Association of Patient-centered Medical Home Designation With Quality of Care of HRSA-funded Health Centers: A Longitudinal Analysis of 2012–2015Hu, Ruwei PhD ; Shi, Leiyu DrPH, MBA, MPA ; Sripipatana, Alek PhD, MPH ; Liang, Hailun DrPH ; Sharma, Ravi PhD ; Nair, Suma PhD, MS, RD ; Chung, Michelle MCSE, MCSA, MCPD ; Lee, De-Chih PhD

Medical Care: February 2018 - Volume 56 - Issue 2 - p 130–138doi: 10.1097/MLR.0000000000000862Original Articles

Objectives: (1) To evaluate the relationship between Patient-centered Medical Home (PCMH) recognition and quality of clinical care among health centers, and (2) to determine whether the duration of recognition is positively associated with cumulative quality improvement over time.

Methods: Data came from the 2012 to 2015 Uniform Data System, health centers’ PCMH recognition status, and the Area Resource File. Health center was the unit of observation. The outcome variables included 11 measures of clinical quality. We pooled all years of data and modeled longitudinal data with generalized estimating equations to examine the degree of improvement in health care quality in health centers with and without PCMH recognition over the years 2012–2015.

Results: Health centers with PCMH recognition generally performed better on clinical quality measures than health centers that did not have PCMH recognition for all years studied. After accounting for health center and county-level potential confounders, health centers with longer periods of PCMH recognition were more likely to have improved their clinical quality on 9 of 11 measures, than health centers with fewer years of PCMH recognition.

Conclusions: Health centers’ length of time with PCMH recognition was positively associated with additive quality improvement. Adoption of the PCMH model of care may serve as a strategy to enhance quality of primary care services.

Department of Health Management, School of Public Health, Sun Yat-sen University, Guangzhou, China

Johns Hopkins Primary Care Policy Center, Johns Hopkins Bloomberg School of Public Health, Baltimore

Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, MD

Department of Information Management, Da-Yeh University, Taiwan, R.O.C

Supported by the China Medical Board (CMB) open competition grant number 15-224.

The authors declare no conflict of interest.

Reprints: De-Chih Lee, PhD, Department of Information Management, Da-Yeh University, Taiwan, R.O.C. E-mail: [email protected].

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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Abstract Author Information

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Page 1 of 2The Association of Patient-centered Medical Home Designation... : Medical Care

4/25/2018https://journals.lww.com/lww-medicalcare/Abstract/2018/02000/The_Association_of_Patient_centered_Medical_Home.4.aspx

Journal of Health Science 5 (2017) 128-134 doi: 10.17265/2328-7136/2017.03.002

The Medical Home Transformation

Namita Azad and Emily Hart

Montefiore Medical Group, 200 Corporate Blvd. South, Suite 175, Yonkers, NY 10701, USA

Abstract: To maintain productivity in today’s healthcare market, it is important for institutions to have a delivery system that allows for transformation and adaptation. This paper introduces the Medical Home Transformation Model which demonstrates the effectiveness of employing a team of embedded coaches within a five-step capacity building program in conjunction with learning collaboratives, the adaptation medium. This model demonstrates the effectiveness of concurrently employing the coaching lifecycle and a five-step capacity building program. Moreover, the model details the formation of multidisciplinary teams at each clinical site, meaningful data reporting at site and physician levels and best practice sharing at collaboratives and seminars. A discussion then demonstrates the success of MMG (Montefiore Medical Group) as it applies the model to its ambulatory care network of 22 health centers in effort to achieve PCMH (Patient Centered Medical Home) recognition, improve clinical outcomes, and document financial benefits. While PCMH is currently the sought after delivery system framework, this paper will also demonstrate the adaptability of the model to any prescribed framework which continues advancement toward the “Triple Aim”. Such a model has enabled MMG to surpass national standards of clinical care within a confirmed vulnerable population and has placed MMG at the forefront for primary care delivery system reform.

Key words: Transformation, PCMH, primary care, quality improvement, innovation, coaching.

1. Introduction

The method by which healthcare is delivered to a

consumer whether it be the individual, the family, or

the community, is ever evolving. In attempt to remain

current, healthcare systems receive constant scrutiny

on the perceived impact of care from a myriad of

reviewers. While the required changes in a delivery

system are dynamic, there is consistent

encouragement towards the evolution of the “Triple

Aim”: improving the patient experience, improving

the health of populations, and reducing the per capita

cost of health care.

To maintain productivity in today’s healthcare

market, it is imperative for institutions to have a

delivery system that allows for transformation and

adaptation. Coaching, in its truest form, has provided

a medium for topic experts to build capacity in novice

apprentices catalyzing this transformation. The

effectiveness of practice coaching has been well

validated throughout the United States and other

Corresponding author: Namita Azad, MPH, research field:

primary care transformation.

countries with advanced health care systems. Kevin

Grumbach et al. note in The Commonwealth Fund

Issue Brief, “Facilitating Improvement in Primary

Care: The Promise of Practice Coaching” states that

coaching has demonstrated dramatic increases in

preventative care measures (compared to control sites)

by as much as 30%. Grubach [1] eloquently

summarizes that “successful strategies in the

intervention included the coaching style of the

practice improvement team, working alongside

practice staff rather than just training them, and testing

incremental changes using PDSA”.

The missing link is the method for which a health

care system can adapt and sustain the practice’s

transformation. This paper introduces the Medical

Home Transformation Model which demonstrates the

effectiveness of employing a team of embedded

coaches within a five-step capacity building program

in conjunction with learning collaboratives, the

adaptation medium. A step-by-step guide

demonstrates the applicability of the parallel processes

in the model as well as best practice suggestions. A

discussion then demonstrates the success of MMG

D DAVID PUBLISHING


129

(Montefiore Medical Group) as it applies the model to

its ambulatory care network of 22 health centers in

efforts to achieve PCMH (Patient Centered Medical

Home) recognition. While PCMH is the current goal

of the delivery system framework, this paper will also

demonstrate the adaptability of the model to any

prescribed framework which continues advancement

toward the ‘Triple Aim”.

2. Methodology

The images displayed in Figs. 1 and 2 demonstrate

the building blocks of creating capacity to implement

a medical home. The embedded coaching team that

employs the coaching lifecycle, is pivotal in

sustainability of the medical home. The first step in

this process, as represented by circle 1 in Fig, 1,

speaks to increasing clinical and operational staffing

inclusive of CCRN (Chronic Care Nurse Managers),

PSR (Patient Service Representatives), and LPN

(Licensed Practice Nurses) to manage sustainability of

the transformation.

The second step is introducing an embedded

coaching team that provides dedicated transformation

support and who works with multidisciplinary care

teams at the site level. The coaching team operates

through a cyclical process displayed by the seven

distinct steps in Fig. 2.

Steps of the coaching lifecycle:

(1) Needs Assessment: Conduct a site visit and

meet with clinical and operational leadership to

understand and identify gaps in patient flow. Review

site specific data to gauge baseline site performance in

areas of focus.

(2) Formation of Multidisciplinary Transformation

Team: Form a multidisciplinary transformation team,

representative of all site disciplines, which is

responsible for planning, testing and leading site

change and dissemination of information to all other

site members.

(3) Vision and Strategy: Communicate rationale,

define goals and align efforts.

(4) Workflow Design and Establishment of Metrics:

Identify measure or area for improvement, outline and

document the decided workflow.

(5) Create and Implement: Develop communication

and roll-out plan for implementation of transformation

activities across the site. Training occurs with all

disciplines.

(6) Redesign & Formalize: Guide transformation

team to redesign and formalize workflows and their

associated processes. This becomes part of the

operational training for all new hires and annual

competency review for existing associates.

(7) Sustain: Provide refresher training and revisit

workflows on a continuous basis. Monitor site specific

data and trends to assess fidelity to transformation

activities.

Narrowing on key focus measures allows institutes

to ensure progress towards system based health care

goals. Circle 3 in Fig. 1, speaks to the necessity of

data and analytics to support monitoring of identified

focus measures for the transformation team at each

site. Obtaining routine and real time data reports

allows the team to work proactively on areas of

opportunity, rather than reactively to historical data.

Care management and care coordination is the core

of the PCMH delivery system. Circle 4 in Fig. 1,

highlights the recruitment of co-located clinical staff

such as health educators, certified diabetes educators,

social workers and behavioral health staff or other

clinical support staff relevant to the patient population.

This comprehensive team ensures the patient and

family is treated as a whole rather than narrowly

focusing on one symptom or problem.

With the need to disseminate standardized workflows

and processes, circle 5 in Fig. 1, identifies a platform

such as a Transformation Collaborative which allows

teams to work in collaboration with each other and

create a shared language. This venue can be used for

best practice sharing amongst the teams, content

experts presenting and the introduction of new

initiatives and programs.


130

Fig. 1 The Medical Home Transformation Model.

Foundational to all this work is the science of CQI

(Continuous Quality Improvement). MMG’s vision is

to create a CQI infrastructure to support success of the

transformation work. Key CQI concepts such as

PDSAs, Pareto Charts, Lean Wastes and Process

Mapping, are taught at the Transformation

Collaboratives and all sites are charged with creating a

plan for a PDSA that they will test when they get back

to the site. The coaching team then manages the

follow-through with this as well as facilitates the

dissemination of these concepts to the rest of the site

staff. The utilization of these tools informs multiple

steps of the coaching lifecycle such as steps 1 and 6,

workflow design and redesign as well as step 5, create

and implement.

3. Results and Discussions

The impact of this model is best demonstrated by

the success within the MMG network. The population

MMG serves is one of the most diverse in the country.

In 2015, there were over 200,000 unique patients of

which over 40% are Medicaid. MMG’s transformation

journey began in 2008 with two ambulatory practices

that were selected as pilot PCMH sites and a team

of two coaches were brought on board to initiate

this transition. The coaches completed the needs

Sharing best practices through routine MMG collaboratives & seminars

Increase in site specific data reporting

Deployment of a coaching team to aid with the recognition

process and evolution of the medical home

Increase in staffing at sites with

CCRNs, LPNs & PSRs

Circle 1

Circle 2

Circle 3

Circle 4

Circle 5

Introduction of ancillary staff

members - health educators, social

workers, psychologists,CEDs ect.


131

Fig. 2 Coaching lifecycle.

assessment at the two health centers and created the

multidisciplinary teams. The needs assessment

quickly identified the demand for additional

support staff to create care management teams CCRNs,

LPNs and PSRs were hired. These initial steps created

the foundation for the transformation model, as

displayed in Figs. 1 and 2. The outcome of utilizing

this methodology was a level 3 PCMH certification

under the 2008 standards for the two sites. The

success seen from the model proved the need for

replicating this staffing structure across the MMG

network which included expansion of the coaching

team.

Over the next 5 years, the MMG sites adopted the

model and with additional coaching support, were able

to achieve PMCH success under the 2008 and then

2011 standards. Through this period, the continual

needs assessment led to formation of a robust

reporting and analytics team, the necessity of having

co-located service providers such as health educators,

social workers, community health workers,

psychologists, psychiatrists, patient educators and

referral coordinators. The dynamic expansion of

staffing and transformation activities required a forum

for best practice sharing and learning that would

facilitate dissemination on a larger scale. Quarterly

held Transformation Learning Collaboratives were the

product which brought interdisciplinary

representatives together to learn tools and techniques

as well as share their success and challenges. These

pieces were the final building blocks to the current

state of the transformation model.

An integral part of the medical home transformation

model is the embedded coaching team that functions

Needs Assessment

Formation of Multidisciplinary

Transformation Team

Vision & Strategy

Workflow Designing & Establishing

Metrics

Creating & Implementing

Plan

Redesigning & Formalizing Workflows

Sustainability

Coaching Lifecycle


132

Fig. 3 MMG transformation example timeline.

Fig. 4 MMG transformation success.

Coaching team worked towards mapping out the

unique patient flow for each MMG site

The data analytics team provided

baseline cycle time data

Information was shared at the

Transformation Collaborative and staff were trained on CQI tools to

catalyze the efforts

Coaching team worked alongside MMG sites to plan and execute PDSAs

and monitor data

Report outs were done at subsequent

Transformation Collaboratives

40%

50%

60%

70%

80%

90%

100%

2012 Q4 2013 Q4 2014 Q4 2015 Q4 2016 Q4

Rat

e

MMG Transformation Success

Pneumovax

Depression Screening > 18

UTD Combo 3

% Diabetics, BP < 140/90

A1C < 8

Colorectal Cancer Screening

UTD HPV

The Medical Home Transformation Model


133

as the catalyst in this process. As is highlighted in

Fig. 2, the steps within the model allow for continuous

monitoring and adaptation of site specific

transformation activities based on clinical need.

The continuous utilization of the transformation

model has fostered the sustainability of its

PCMH standards since adoption. With the evolving

standards of patience centered care, this model

has enabled MMG to stay up to date with its

certification as well as recertify the MMG sites under

the 2014 standards. To date the 22 sites are certified

under the 2011 standards of which 10 have been

recertified as level 3 PMCHs under the 2014

standards.

With the MMG network functioning as a

comprehensive PCMH, there have been vast

improvements in the clinical quality metrics. There

have been numerous initiatives that have surfaced

through different departments of MMG and the

collaboration between the coaching team and these

departments have led to success in the respective

metrics of focus. One such collaboration was with

MMG and the Montefiore CMO (Care Management

Organization), the Hospital Medical Home grant,

which led to a reduction in Medicaid readmission by

22%. Other successes of the Medical Home

Transformation Model over the last 4 years have

included an increase in pneumovax vaccination rates

by 9%, increase in depression screening rates, for ages

18 and older by 16% and an increase in Combo 3 and

HPV vaccination rates by 21%.

The CQI knowledge building at the transformation

collaboratives and its weaving into the coaching

lifecycle has lent itself to the sustainability of this

work. One of the metrics that this model has

impacted is reduction of patient cycle time. Patient

cycle time is a key component to the patience

experience and access. MMG sites started this

process by mapping out their current state patient

flow map as a spaghetti diagram with baseline data

(time in minutes) respective to each step. This

helped them identify both value added and non-valued

added steps and where the wastes lived. PDSAs were

designed to start working on each of the wastes

identified. Numerous PDSA cycles were conducted

and in a 6-month period, more than 75% of MMG

health centers were able to reduce their patient cycle

time by 10% which accounted to over 40 min in some

health centers. There was a steady improvement in the

patient experience scores in the domains of physician

communication and care coordination. One of the

critical factors to team based care, as per the

PMCH 2014 standards, is the utilization of huddles.

This practice proved to be one of the key drivers in

reduction of patient cycle time. Site staff used the

huddles as the venue to do pre-visit planning for

patients. Some health centers conducted huddles

twice a day—the first being done in the morning

to plan the operational needs of that day and the

second being done at the end of the day to plan the

clinical needs of the following day. This process

helped facilitate targeted and coordinated care for the

patient.

Fig. 2 below demonstrates how the Medical Home

Transformation Model was the framework that

allowed for this success.

4. Conclusions

The Medical Home Transformation Model has

provided MMG with the capacity to create macro

level cultural changes, exhibited through its team

based care delivery which operates within a solid CQI

infrastructure. This has enabled MMG to surpass

national standards of delivered clinical care within a

highly vulnerable population and has placed this

health system at the forefront for primary care

delivery system reform.

The anticipated reform of primary care will bring

responsibility to institutes to address more than just

the patient’s current medical condition but rather look

at the patient and their community as a whole. Moving

forward, MMG’s vision is to maximize the level of


134

patient engagement and satisfaction through optimal

tools such as electronic patient portals, shared patient

health information platforms and patient and

community advisory councils.

Reference

[1] Grumbach, K., Bainbridge, E., and Bodenheimer, T. 2012. Facilitating Improvement in Primary Care: The Promise of Practice Coaching. The Commonwealth Fund, 1-13.

Research Article

The Reduction in ED and Hospital Admissions in Medical Home Practices Is

Specific to Primary Care–Sensitive Chronic Conditions

Lee A. Green M.D., M.P.H., Hsiu‐Ching Chang Ph.D., M.S., ... See all authors

First published: 2 March 2017https://doi.org/10.1111/1475-6773.12674

Abstract

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ObjectiveTo determine whether the Patient‐Centered Medical Home (PCMH) transformation reduces hospital and ED utilization, and whether the effect is specific to chronic conditions targeted for management by the PCMH in our setting.

Data Sources and Study SettingAll patients aged 18 years and older in 2,218 primary care practices participating in a statewide PCMH incentive program sponsored by Blue Cross Blue Shield of Michigan (BCBSM) in 2009–2012.

Study DesignQuantitative observational study, jointly modeling PCMH‐targeted versus other hospital admissions and ED visits on PCMH score, patient, and practice characteristics in a hierarchical multivariate model using the generalized gamma distribution.

Page 1 of 2The Reduction in ED and Hospital Admissions in Medical Home Practices Is Specific to Primary Care–Sensitive Chronic Conditions - Green - ...

4/25/2018https://onlinelibrary.wiley.com/doi/pdf/10.1111/1475-6773.12674

Supporting Information

Principal FindingsBoth hospital and ED utilization were reduced proportionately to PCMH score. Hospital utilization was reduced by 13.9 percent for PCMH‐targeted conditions versus only 3.8 percent for other conditions (p = .003), and ED utilization by 11.2 percent versus 3.7 percent (p = .010). Hospital PMPM cost was reduced by 17.2 percent for PCMH‐targeted conditions versus only 3.1 percent for other conditions (p < .001), and ED PMPM cost by 9.4 percent versus 3.6 percent (p < .001).

ConclusionsPCMH transformation reduces hospital and ED use, and the majority of the effect is specific to PCMH‐targeted conditions.

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Page 2 of 2The Reduction in ED and Hospital Admissions in Medical Home Practices Is Specific to Primary Care–Sensitive Chronic Conditions - Green - ...

4/25/2018https://onlinelibrary.wiley.com/doi/pdf/10.1111/1475-6773.12674