Becoming a Patient-Centered Medical Home

In 2011, one of Kansas-based St. Luke Medical Group's major payers approached the 18-office multispecialty group about joining a new quality initiative. The insurer would pay participating practices a monthly per-patient fee for coordinating the care of its members provided that each practice qualified as a Patient-Centered Medical Home (PCMH).

The offer triggered the group's decision to pursue National Committee for Quality Assurance (NCQA) recognition as a level 3 PCMH, the highest qualifying level. Even though the group was already moving toward a medical home style of practice, it would take another two years to satisfy all of the NCQA's requirements.

"We already had some of the elements of a medical home in place but there was still a lot to do," says Michael Munger, a family physician and medical director at St. Luke's South Primary Care in Overland Park, Kan., with 11 primary-care physicians and two NPs. "We had to really amp up our test and referral tracking and work on our transitions of care between the acute and ambulatory settings."

Not everyone in the group was on board at first, Munger acknowledges. But that changed as it became apparent that their hard work was paying off.

"We've started to see movement in the market since we became recognized in terms of payers reimbursing based on quality and performance, and that's bringing real dollars into the practice," says Munger. "Even the skeptics in the group are now saying that becoming a PCMH positioned us to be successful."

Getting Started

St. Luke's has already had one major component of a PCMH in place since 2009: EHRs. In addition, the group was already using some chronic disease measurements related to diabetes, coronary artery disease, and other common conditions, and was familiar with setting goals of care and tracking physician performance.

The group used the NCQA's list of six must-pass PCMH elements as an organizing framework for moving forward (see sidebar). In order to achieve level 3 recognition they would have to score at least 85 percent on 27 elements or standards within six broad categories of care: patient-centered access; team-based care; population health management; care management and support; care coordination and care transitions; and performance measurement and quality improvement.

Munger, who serves on the board of the American Academy of Family Physicians and was already well-versed in the medical home concept, took on the role of overall physician champion. In addition, each individual office appointed its own champion to help coordinate PCMH activities.

"I embedded myself with as much knowledge as I could," says Munger. "It was sort of a leap of faith because not much was changing in terms of reimbursement in late 2011 to 2012, but I felt we needed to move in this direction sooner rather than later."

Dedicating Staff Time

Because the group already had EHRs in place, most of the costs of getting started focused on personnel rather than equipment or infrastructure, says Munger. For example, a group director who had been managing the group's 11 primary-care offices switched gears to spend most of her time on PCMH issues. In addition, a full-time assistant was hired to help with preparing and uploading documents to the NCQA site.

Munger reduced his patient load by about 15 percent during the process but both he and the primary-care group director still struggled to juggle their PCMH responsibilities with the demands of their regular jobs. It was not until after the group achieved recognition in October 2013 that there was room in the budget to hire several registered nurses to help with care coordination and transitions after hospital discharge.

"Everyone had very busy lives during the transition," says Munger. "Human resources are the primary cost once you have the technology in place."

Facing Challenges

Getting buy-in from everyone in the practice was the most challenging part of the process, says Munger.

"We were embarking on a real redesign of work flows and thought processes going from an episodic model of care to thinking beyond individual patients to population-based care," he says. "Change management was very important in order to get buy-in from everyone, from physicians to office assistants, and make sure they understood how this will improve patient care."

Many employees were skeptical that the long-term benefits would eventually outweigh the costs - in both time and money - of gaining medical home status.

"At the time, Blue Cross-Blue Shield was offering to pay us for care coordination but there were no other plans in our market doing this and a lot of people wondered what we would get out of it," says Munger. "They wanted to know how this would really help the patient and whether we would see returns on adding a lot of extra work and personnel."

Adjusting to team-based care was another hurdle in the beginning, he says. While clinicians agreed with the concept of teamwork and sharing patient care with advanced practitioners, it has taken time for them to truly embrace it.

"No one would want to give them up now but a year or so ago, there were a lot of misunderstandings about what our nurse coordinators would do and how they would improve care," says Munger.

Soon after St. Luke's received recognition, Munger hired two nurse coordinators for his office and plans to add three more by September 2015. The group has also shifted more patient care responsibilities to triage nurses and medical assistants to ensure that they work at the top of their licensures.

"Achieving your recognition is just the beginning of your journey to transform your practice," says Munger. "For us, it continues to be a work in progress."

Reaping the Benefits

Patients began to take notice when St. Luke's expanded access to care. The group now offers same-day appointments at all locations and three offices have opened walk-in clinics managed by nurse practitioners, Monday through Saturday.

"The walk-in clinics have become a way to attract new patients," says Munger. We've increased our patient load by about 19 percent since the clinics opened."

The group also has a growing revenue stream from insurer-based incentives and management fees, he says. For example, Medicare offers a monthly per-beneficiary care management fee to practices that meet certain criteria and several other large insurers offer bonuses for meeting certain quality targets related to chronic disease management and population health.

"Becoming a PCMH has given us leverage in negotiating with payers," says Munger. "We're seeing extra revenue coming in because so many programs are interested in what we're doing around managing populations."

Making the Grade as a Medical Home

The National Committee for Quality Assurance uses a 100-point scoring system consisting of 27 individual elements of care, including six baseline must-pass items. Practices must achieve a passing grade on all 27 elements to become recognized as a level 3 patient centered medical home. Elements are grouped into six broad categories:

1. Patient-centered access

• Patient-centered appointment access (must pass)

• 24/7 access to clinical advice

• Electronic access

2. Team-based care

• Continuity

• Medical home responsibilities

• Culturally and linguistically appropriate services

• The practice team (must pass)

3. Population health management

• Patient information

• Clinical data

• Comprehensive health assessment

• Use data for population management (must pass)

• Implement evidence-based decision support

4. Care management and support

• Identify patients for care management

• Care planning and self-care support (must pass)

• Medication management

• Use electronic prescribing

• Support self-care and shared decision making

5. Care coordination and care transitions

• Test tracking and follow-up

• Referral tracking and follow-up (must pass)

• Coordinate care transitions

6. Performance measurement and quality improvement

• Measure clinical quality performance

• Measure resource use and care coordination

• Measure patient/family experience

• Implement continuous quality improvement (must pass)

• Demonstrate continuous quality improvement

• Report performance

• Use certified EHR technology

Source: PCMH 2014 Scoring. NCQA.

Janet Colwellis a West Hartford, Conn.-based freelance writer specializing in healthcare. With more than 20 years experience as a journalist, she writes frequently about clinical and practice management issues for several national health industry publications. She can be contacted at editor@physicianspractice.com.