DIGESTM E D I C A L H O M E

N E W S F R O M T H E S A F E T Y N E T M E D I C A L H O M E I N I T I AT I V E

This issue of Medical Home Digest poses some frequently

asked questions about PCMH transformation: What

evidence supports the PCMH Model of Care? How should

we measure improvement? How can leadership set the stage

for successful transformation?

The issue begins with an article highlighting recent

recommendations from the PCMH Evaluator’s Collaborative.

The following article describes recent research on PCMH cost

and quality outcomes and offers thoughts on what is needed

to build the PCMH evidence base. The Digest continues with

an article that outlines essential leadership roles and behaviors

for effective transformational change. It concludes with an

announcement about a new public domain online resource

for practice facilitators built on the SNMHI framework.

Introduction

The Medical Home Digest is a newsletter devoted to

keeping you informed about medical home transformation

in the safety net. This newsletter is brought to you by the

Safety Net Medical Home Initiative, which is sponsored by

The Commonwealth Fund. Each issue highlights critical

aspects of patient-centered care and PCMH transformation.

Spring 2013

I N T H I S I S S U E :

Introduction .....................................................................................1

Measuring the Success of Medical Homes: Recommendations from the PCMH Evaluators’ ..................2

Evidence that the Medical Home Works ................................4

Essential Leadership Roles for

Transformational Change ............................................................5

New Guide for Practice Facilitators:

Coach Medical Home ....................................................................9 R E S O U R C E S :

Using a Patient-Centered Care Plan and Teamwork to Support Self-Management (March 28, 2013)Speakers: Larry Mauksch, MEd, LMHC, University of Washington Department of Family Medicine (Seattle, WA); Berdi Safford, MD, Family Care Network (Bellingham, WA)

Closing the Loop with Referral Management (February 26, 2013) Speaker: Linda Thomas-Hemak, MD, President and CEO, The Wright Center for Graduate Medical Education (Scranton, PA)

Tools to Enhance Patient Engagement (January 24, 2013)Speakers: Chris Delaney, MBA, Insignia Health (Portland, OR); Cathy Davenport, RN, BSN, PeaceHealth (Eugene, OR); Shannon Gilbert, MHA, MultiCare Health System (Tacoma, WA); Jim Weiss, MD, Primary Health Medical Group (Meridian, ID)

Planned and Mini-Group Medical Visits (January 10, 2013)Speakers: Devin Sawyer, MD, and Jamacca Larman, CMA, St. Peter Family Medicine Residency Program (Olympia, WA)

Spread and Sustainability in Medical Home Transformation (December 19, 2012) Speakers: Mindy Stadtlander, MPH, CareOregon (Portland, OR); Robert Reid, MD, PhD, Assoc. Investigator, Group Health Research Institute (Seattle, WA)

Safety Net Medical Home Initiative

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There are currently more than 90 commercial health plans, 42 states, and three Medicare initiatives testing the Patient-Centered Medical Home (PCMH) Model. Yet, while elements of the medical home have been shown to be associated with better quality and lower cost, there are only a few high-quality published evaluations of the impact of the PCMH model as a whole. There is an urgent need for rigorous information to strengthen the evidence base of the medical home in order to ensure effective implementation of the model.

PCMH evaluations can help clarify what’s working well, shed light on what needs improvement, and identify contextual factors that facilitate implementation. The purpose of medical home evaluations is not to issue a verdict about whether or not PCMHs “work.” Years of research from the U.S. and abroad show that strong primary care is essential to achieve high performance in our health care system. Alternatively, the goal of current PCMH evaluations is to learn from the numerous demonstrations and programs and help guide effective implementation that will lead to better patient care, lower cost, and improved population health.

In an effort to harness and share lessons from the many disparate medical home pilots and evaluations under way, The Commonwealth Fund established the Patient-Centered Medical Home Evaluators' Collaborative in 2009. The objectives of the Evaluators’ Collaborative are to:

1. Reach consensus on a standard core set of outcome measures and instruments;

2. Share the consensus on instruments, metrics, and/or methodological lessons with interested researchers around the country; and

3. Foster an ongoing and supportive exchange where evaluators share ideas that improve their evaluation designs, analytic approach, and interpretation of findings.

More than 85 researchers participate in the Evaluators’ Collaborative. To achieve consensus on a core set of measures, five work groups were developed to focus on key outcomes or domains: medical home implementation, patient experience, cost/utilization, clinical quality, and clinician/staff experience. Each work group reviewed the literature, developed logic models, and met regularly to debate effective and feasible measures to evaluate medical home pilots in each dimension. Given the importance of the patient perspective in evaluating the medical home, we created a separate workgroup that focused on patient experience.

In May 2012, the Evaluators’ Collaborative released its recommended core set of standardized measures for two of the five work groups: cost/utilization and clinical quality. The Official Summary Statement is posted on the Commonwealth Fund’s website. Table 1 on the following page summarizes the core set of measures to evaluate cost and utilization outcomes in PCMH evaluation studies. The minimum measurement set to monitor changes in utilization includes measures of emergency department (ED) visits, hospitalizations, and readmissions. For cost measures, there was consensus that evaluations should always include analysis of total per member per month cost for high-risk patients, since the PCMH initiative is most likely to detect a measureable effect on this patient population. While there was widespread agreement that measures should be risk-adjusted to account for complexity of the patient population, there was diversity of opinion about which method of risk-adjustment to apply.

In terms of clinical or technical quality outcomes, the Evaluators’ Collaborative reached consensus on a core set of principles. Due to concerns about variation in the emphasis of local PCMH pilots as well as diversity of PCMH pilot populations, a uniform minimum

Measuring the Success of Medical Homes: Recommendations from the PCMH Evaluators’ Collaborative

Melinda Abrams, MSThe Commonwealth Fund

Asaf Bitton, MD, MPHThe Commonwealth Fund

Meredith Rosenthal, PhD The Commonwealth Fund

continued

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quality measurement set was viewed as inappropriate. However, a core set of principles was intended to encourage rigor and flexibility, as well as consistency in reporting of technical quality by PCMH evaluators. Since the first principle calls for evaluators to use “standardized, validated, nationally recognized measures,” the Clinical Quality work group did put together a suggested list of measures from which PCMH evaluators could select items for their evaluations. For those evaluators interested in their data being used as part of a meta-analysis, the group did agree to a very limited, core set of clinical quality measures. Both the long list of technical quality measures and the short list of measures for possible meta-analysis are listed in the Official Statement.

Given the importance of the patient perspective in evaluating the medical home, a separate work group focused on outcomes measures to assess patient experience. This group conducted a review of various patient surveys being administered in a wide number of PCMH evaluations. The team also commented on the strengths and weaknesses of the various questionnaires as an evaluation tool. Ultimately, the findings of this work group were

incorporated into ongoing research by a team at Harvard, Yale, and the National Committee for Quality Assurance to develop and test the new PCMH-CAHPS survey (Consumer Assessment of Healthcare Providers and Systems), which was officially released by the U.S. Agency for Health Care Research and Quality in January 2012. The survey can be found here.

The PCMH Evaluators’ Collaborative continues to meet and is open to all researchers actively working on a medical home evaluation. However, it’s important to remember that efforts to reach consensus on a core set of standardized outcome measures for PCMH evaluation are only a small part of a much larger and broader spectrum of PCMH measurement. There are measures to monitor PCMH transformation (e.g., PCMH-A developed as part of the Safety Net Medical Home Initiative) and measures of accountability (e.g., NCQA or URAC measures for PCMH certification). We hope these recommended outcomes measures for PCMH evaluation will strengthen the quality of medical home research, inform future medical home implementation, and ultimately, improve primary care policy in the United States.

Table 1. Core Cost/Utilization Measures for Cross-Study Comparison in PCMH evaluations

Utilization

Emergency department visits, ambulatory-case sensitive (ACS) and all

Acute inpatient admissions, ACS and all

Readmissions within 30 days

Cost

Total per member per month costs

Total per member per month costs for high-risk patients

Technical issues: all utilization and cost issues should be risk adjusted; method of pricing should be transparent and standardized if possible

Source: The Commonwealth Fund PCMH Evaluators’ Collaborative.

Table 2. Core principles and measures for assessing clinical quality in PCMH evaluations

Quality Measurement Principles

1. Evaluators should use standardized, validated, nationally endorsed measures. The PCMH Evaluators’ Collaborative Quality Workgroup recommends selecting a group of quality measures from Table 3. For purposes of meta-analysis, we recommend the measures listed in Table 4 as a core set.

2. Evaluators should select measures from each of the following areas of primary care: preventive care, chronic disease management, acute care, overuse and safety.

3. Evaluators should apply a validated approach to data collection. This is particularly important if pulling measures from the medical record or EHR.

4. Evaluators should use consistent measures across practices within a demonstration.

Source: The Commonwealth Fund PCMH Evaluators’ Collaborative.

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If you’ve been on the medical home

transformation journey with us for the last

few years you’ve probably done a lot of work

organizing patient panels, improving access,

reorganizing staff into teams, and gathering

lots and lots of data. You are not alone.

Hundreds of patient centered medical home

demonstration programs are happening across

the country. Results about improvements in

care, patient and staff experience, cost saving,

and more are just starting to come in. The Commonwealth

Fund has been a leader in organizing data from different PCMH

programs so we can better compare the results and understand

what works and what doesn’t. For more on the PCMH Evaluators’

Collaborative efforts, see the companion article by Melinda

Abrams and colleagues.

Several recently published reports discuss early results of

these medical home transformation efforts.1, 2, 3 Though

only representing a portion of the medical home programs

sponsored by commercial health plans, state Medicaid programs,

foundations, federal agencies, and others, these reports do provide

a first look at the questions we are all asking about primary care

redesign. Does care improve? Are patient and staff experiences

bolstered? Are costs reduced?

The most convincing of these evidence reviews is a report

commissioned by the Agency for Healthcare Research and Quality

and conducted by researchers at the Duke University Evidence-

based Practice Center. The authors of this systematic review

sifted through more than 5,700 peer-reviewed papers to find and

carefully analyze 19 comparative studies. Across all studies, the

medical home showed some promising results:3

• Improved patient experience of care.

• Improved delivery of preventive care services.

• Improved staff experience.

• Reduced emergency department visits.

These findings are great news and a testament to the tremendous

amount of work required to become a medical home. However,

questions remain including improved health outcomes and

whether the medical home can reduce health care costs. Many

of the medical home programs included in this systematic review

had different operational definitions of what it means to become

a medical home. Some programs focused more on cost reduction

than others, and many of the programs had been underway

for fewer than two years. The authors conclude that there is

not enough evidence to be sure about the impact on clinical

outcomes or cost reductions. That means we need a lot more data

from sites about what is working and what is not!

As part of the Safety Net Medical Home Initiative, researchers

from the University of Chicago have been collecting data about

changes to patient health outcomes, cost, utilization of health

services, and patient and staff experience, as sites have become

medical homes. After the SNMHI concludes, researchers will

publish their findings, adding to a growing body of knowledge

about the effectiveness of medical homes and providing some of

the most detailed information yet on how medical homes work

for vulnerable populations. Keep your eyes out for these new

medical home papers!

1. Nielsen M, Langner B, Zema C, Hacker T, Grundy P. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost and Quality Results. Patient-Centered Primary Care Collaborative. 2012. Available here.

2. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2):105-16.

3. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178.

Evidence that the Medical Home Works

Katie Coleman, MSPHMacColl Center for Health Care Innovation

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Transformational change, like Patient-Centered

Medical Home (PCMH) transformation,

requires not only adapting new processes

and procedures, but attending to the way

people work and think together. Identifying

essential leadership roles and responsibilities

and setting up clear structures for

communication and decision-making help

to foster change-hardiness in yourself and

your team as well as create avenues on which

to move toward your vision.

Everyone is capable of being a leader—of influencing and

empowering action in a positive direction. In a primary care

practice, there are typically several leadership positions

including practice owners/Executive Directors, clinical leadership

(e.g., Medical Director, Nursing Director), and administrative leaders

(e.g., CFO, COO). There are also leadership roles (e.g., sponsor, team

leader, informal leaders). Successful PCMH transformation requires

senior leaders to support change efforts and provide necessary

resources to make and sustain those changes. Staff in leadership

roles, whether in leadership positions or not, also need to model

behaviors essential to achieving those changes.

This article provides an overview of common leadership roles

required to support large-scale change/transformation efforts and

provides tips and examples of supportive behavior for those in

leadership roles.

Engaged Sponsorship – a key to success

While all leaders may (and ideally, do) have formal and informal

influence upon a group, a sponsor has the means to support the

change in vital ways. An effective sponsor directs the distribution

of necessary resources (e.g., time, equipment, space, money), is

able to inspire enthusiasm in others to achieve goals, and has

the hiring/firing power to put capable people in the right roles.

An effective sponsor also desires the change as transformational

change requires determination and desire. In other words, a

sponsor is required to have resources, authority, and desire (RAD).

Often the sponsor is in the CEO/President position or owns and

directs the practice. Every major change effort requires a sponsor

in these capacities. Some practices have a team of sponsors. In

this case, it is essential to be clear about specifically who will be

the executive sponsor of your change initiative.

Project leader/team leader - While a team leader may not

have the authority to allocate resources (e.g., staff time, capital

expenses), an effective team leader can leverage his/her influence

to build a spirit of collaboration to keep the team engaged and

productive. The project leader may also be the team leader and

have staff on the team directly reporting to him/her. While project

leaders/team leaders are frequently the physician or nurse leader

of a quality team or the clinic manager, they do not need to be

in a formal position of authority. An effective team leader has the

ability to guide the team’s work and help the team stay focused on

the goal. A good team leader also attends to healthy interpersonal

dynamics in the team and therefore must have the team's respect

and trust. Additionally, staff in this role must have clear and

frequent communication with the sponsor as they are likely the

bridge between sponsor and team.

continued

Essential Leadership Roles for Transformational Change

Cynthia Manning, MAVibrant Consulting

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Informal leader/influencer - This staff member has a great deal of

influence and is often a leader regardless of official role. Influential

strength is gained through demonstration of ability and character;

they do what they say they will do and they are able to do it.

Project leaders will do well to encourage such people to play

critical roles on the change team, providing their influence is in

line with the strategic direction of the organization.

For every leader, leading a transformational change effort

challenges both your internal and external resources. While you

are in the thick of juggling myriad responsibilities, everything you

do, say, or do not do, even facial expressions, are magnified to

others working under your leadership. While observing you, your

team is busy consciously and unconsciously interpreting their

observations. Effective leaders strive to be keenly aware of their

impact, keep themselves and others focused upon the vision,

support systems, and processes to keep everyone moving in the

same direction. A leader must strive to walk the talk at all times.

A cinch, right?

Following is a review of some of the essential tasks required of

leaders engaged in transformational change. These tasks are not

necessarily sequential, and it is beneficial to repeat and review

them regularly.

Sponsor Tasks:

Clarify and build commitment to the vision.

• If sponsorship is shared within the organization, as may be the

case with an executive leadership team, it is essential that all

sponsors be in agreement with the vision. Responsibility for

the change project may be delegated to one person, but this

person must have the support of the executive team and board

of the whole organization.

• Evaluate your practice’s capacities. Do you have the necessary

resources to support making changes? Can you involve staff

in redesign meetings? Is there a budget for necessary

equipment/software purchases? Are you adequately staffed?

Do you have room in your budget to provide additional training

to staff when needed?

• Communicate to the organization a clear vision of your

practice’s desired state, including rationale for the need to

change. This may include presenting a formal business case.

Communication of a clear vision will need to be repeated

frequently through multiple modes (e.g., email, memos,

newsletter, message boards, meetings, employee

performance reviews).

• Clarify the major goals (both required and desired) for

the project.

Identify a leader for your change team.

• This person may be working in a day-to-day capacity in

the team, or they may be a facilitator from other areas of

your organization.

• They must have an ability to earn the trust of the team,

demonstrate competency and integrity, and have the skill to

facilitate team processes.

• The team leader must be able to advocate for team resources

and provide feedback and coaching to team members.

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Clarify the decision-making processes and authority of

the team.

• Since the final decision about changes rests in your authority to

sanction them, the project team needs to know how you want

the team to participate with you in decisions related to quality

efforts. Will you be making all decisions about what quality

efforts to engage in, who to involve, etc., or will you consult

with the team and then decide after you have seen evidence

and suggestions? Will quality efforts be decided upon by

consensus or majority rule? The decision-making process must

be consistent and transparent.

Set up regular progress report sessions with the team leader.

• This is a time for honest dialogue. Make it safe for the team

leader to bring up concerns and frustrations. Find solutions

collaboratively. This is also a time to acknowledge progress and

the accomplishment of project milestones.

Sponsor/Team Leader/Manager tasks:

Appoint the project team.

• Bring a cross representation of roles into the team. Given the

choice, invite those who work well with others and who have

enthusiasm for the project to be team members. Inviting the

recalcitrant in hopes of winning them over often results in the

need to apply a considerable amount of effort to keep them

positively engaged. Negative attitudes can have a very

negative impact upon team morale and even a team’s ability

to think creatively.

• Project team members need to know the scope of their

responsibilities and how their work on the team will be

balanced with everyday tasks. Will team members be relieved

of some of their everyday tasks to make adequate time for

their participation? The team needs dedicated time and

meeting space. Without time and space, a team simply

cannot do its work.

• Nurture two-way communications. Sponsors need to be kept

informed and the team needs to know what the sponsor is

thinking about progress. A crucial sponsor role is to remove

roadblocks to team progress (e.g., persuading staff to participate

in tests of change, creating time for the team to meet, providing

timely access to essential information).

Team leader tasks:

• Help the team agree upon processes for bringing up issues,

making decisions, and working through conflicts. Together,

create a shared vision and clarify meeting attendance

commitment. These become the group behavioral agreements

and charter and need to be reviewed and adjusted (when

necessary) on a monthly basis.

• Facilitate goal setting with the team. The major goals of the

project are the “big pieces” and set by the sponsor. Help the

team design smaller components of these goals, identify steps

to getting there, and influence the order in which they are

carried out. The team can and should apply their knowledge

and experience of how things work “in the real world” to discern

appropriate and effective tests of change.

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• The team needs to agree on how they will make decisions in

their efforts. Will they use majority vote or consensus? While

majority vote may seem faster at first, time is often spent later

managing the frustrations and disappointments of those

that have been over-ruled. The consensus process allows for

concerns and issues to be openly discussed and understood

from different points of view.

• Listen. Listen. Listen. Ask questions. If someone brings up

a concern, stay curious. Ask, “What would it look like if this

problem were solved?” Keep progress notes and charts visible

for the team and communicate to the team.

• Think small. Small tests of change by small numbers of

participants. Cross-functional project team meetings are

essential. In addition, the team can appoint a small sub-team to

meet on the fly and make small tests of change related to larger

project goals.

• All teams operate by agreements, either explicit or implicit,

which guide dynamics that impact how diverse roles or

opinions are included, how disagreements are handled,

how decisions are followed through, and so on. Foster the

team's understanding of change dynamics as well as their

understanding and appreciation of different styles and

perspectives. As the team grows in its ability to reflect and learn

together, it will become more effective and efficient in it's ability

to grapple with the myriad challenges that transformational

change offers.

• Teams need positive feedback. Members need to know

when they are doing a good job, and need to be recognized

and encouraged in their work. Team members sometimes

experience criticism from other employees who view team

meetings or “special projects” as goof-off time, or less valuable

than working on day-to-day tasks. Posting frequent updates

regarding team progress/changes can help build credibility

for team members and serve as a reminder that they are

making a difference.

A note to sponsors, team leaders, managers: You are a walking

broadcast of the tone and culture of your practice. How you

interact with everyone will be watched and recorded in the minds

of the team, and played back repeatedly. When you are ambivalent

or discouraged, the team will notice this and their commitment

will waver accordingly. Listen, listen, listen. People will respond

more positively to your earnest conviction if they experience being

listened to when they have concerns.

I M P L E M E N T A T I O N

SAFETY NET MEDICAL HOME INITIATIVE

Strategies for Guiding PCMH Transformation

I M P L E M E N T A T I O N G U I D E

ENGAGED LEADERSHIP

May 2013

TA B L E O F C O N T E N T SIntroduction .......................................................... 2 The Change Concepts for Practice Transformation: A Framework for PCMH ........ 2Chart the Course: Build Will for Change ............... 3 Make the Case ............................................... 3 Clarify Roles and Responsibilities ................... 5Case Study: Encouraging Leaders at Every Level ..................... 7 Develop Communication Strategies ............... 8 Generate Ideas, Foster Innovation.................. 8 Identify and Mentor Champions ..................... 9Use Data to Drive and Guide Improvement.......... 9 Support QI Teams ..............................................12Embed PCMH in the Organization .......................13 Strategic Planning ..............................................13 Hiring and Training ..............................................13Support and Sustain Change by Ensuring Adequate Time and Resources ............................15 Protected Time for Improvement ...................15 Financial Resources .......................................15Case Study: Leadership’s Integration of PCMH ..18Manage Change ..................................................19Conclusion .......................................................... 22Use Proven Strategies: The Institute for Healthcare Improvement’s Seven Leadership Leverage Points for Organization-Level Improvement ........................ 23Additional Resources .......................................... 27Appendix A: Examples of System-Level Measures ..................................... 31Appendix B: Health Information Technology ....... 32

IntroductionAn organization adopting the Patient-Centered Medical Home (PCMH) Model of Care is making a commitment to system-wide transformation. Staff at all levels of the organization must be willing to continually examine processes, adapt to change, and make improvements. These sweeping and transformative changes require the visible and sustained engagement and tangible support of a wide range of leaders including executive leaders (e.g., CEO, Executive Director), financial leaders (e.g., CFO), board members, funders, community supporters, and even payers.

Leaders drive change within their organizations from the top down and the bottom up. Leaders inspire providers and care teams to re-imagine care delivery and reconsider how the organization interacts with patients.

Leaders facilitate PCMH transformation by charting the course for change and supporting and sustaining change efforts. For PCMH transformation to be successful, leaders must provide the necessary time and resources, remove barriers, and provide continuous inspiration and motivation for staff. Most importantly, leaders must implement strategies that make change possible by fostering and encouraging a supportive environment for staff. While guiding their organization through transformation, leaders will need to develop specific strategies. Leaders will need to develop protocols for empanelling patients to ensure continuity of care, address pushback as care team members’ roles change, find ways to protect time for care coordination, and encourage staff to include patients and families on quality improvement (QI) teams.

Look for additional tips and strategies in the updated SNMHI

Engaged Leadership Implementation Guide, available now.

Additional Resources

Anderson LA, Anderson D. The Change Leaders’ Roadmap: How

to Navigate your Organization’s Transformation. San Francisco, CA:

Pfeiffer; 2001.

Scholtes PR, Joiner BL, Streibel BJ. The Team Handbook, 3rd ed.

Madison, WI: Oriel; 2003.

R Galford, AS Drapeau. The enemies of trust. Harvard Business

Review. 2003; 2 :88-95.

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Practice facilitation or coaching and learning communities

are proven clinical improvement strategies for successful

Patient-Centered Medical Home (PCMH) transformation. To add

to the body of publicly available knowledge about practice

facilitation, Qualis Health and the MacColl Center for Health Care

Innovation created the online curriculum: Coach Medical Home:

A Practice Facilitator’s Guide to Medical Home Transformation.

The curriculum is built on the Safety Net Medical Home

Initiative’s framework for practice transformation and designed

to help practice facilitators implement the PCMH Model within

the safety net. Content draws on lessons learned from the

Initiative’s practice coaches.

The goal of Coach Medical Home is to offer any practice

facilitator in any setting nationally support for their work with

patient-centered medical home transformation. To support

transformation, the curriculum contains real world, real-time

tools, and resources and consists of six modules. Each module

contains action steps for practice facilitators to implement

PCMH transformation, provides tips, and links the reader to tools.

Modules also include links to a PDF handbook and companion

PowerPoint presentation that can be easily printed.

The Coach Medical Home curriculum modules include:

Module 1: Getting Started instructs practice coaches on

establishing a relationship with a practice and kick starting the

transformation process.

Module 2: Recognition and Payment introduces key contextual

factors including payment and recognition that need to be

taken into account when working with a team to develop a

transformation strategy.

Module 3: Sequencing provides a framework and coaching

strategies for breaking the transformation process into

manageable phases and steps.

Module 4: Measurement describes the central role of

measurement in transforming care—including enabling teams

to identify priorities, monitoring progress, and keeping focused

on goals.

Module 5: Learning Communities introduces effective

strategies for encouraging teams to motivate, support, and

learn from each other.

Module 6: Sustain and Spread provides ideas for maintaining and

spreading the changes beyond the active PCMH transformation

period—focusing on long-term care improvements.

For more information visit: www.CoachMedicalHome.org

New Guide for Practice Facilitators: Coach Medical Home

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Safety Net Medical Home Initiative

This is a product of the Safety Net Medical Home Initiative, which is supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff. The Initiative also receives support from the Colorado Health Foundation, Jewish Healthcare Foundation, Northwest Health Foundation, The Boston Foundation, Blue Cross Blue Shield of Massachusetts Foundation, Partners Community Benefit Fund, Blue Cross of Idaho, and the Beth Israel Deaconess Medical Center. For more information about The Commonwealth Fund, refer to www.cmwf.org. The objective of the Safety Net Medical Home Initiative is to develop and demonstrate a replicable and sustainable implementation model to transform primary care safety net practices into patient-centered medical homes with benchmark performance in quality, efficiency, and patient experience. The Initiative is administered by Qualis Health and conducted in partnership with the MacColl Institute for Healthcare Innovation at the Group Health Research Institute. Five regions were selected for participation (Colorado, Idaho, Massachusetts, Oregon and Pittsburgh), representing 65 safety net practices across the U.S. For more information about the Safety Net Medical Home Initiative, refer to: www.qhmedicalhome.org/safety-net.