Ali Shropshire, clinical nurse practitioner, talks with a patient at USA Stanton Road Clinic. The clinic recently was recognized as a Level 2 patient-centered medical home.
The recognition standards, developed by the National Committee for Quality Assurance (NCQA), “promote looking at each patient as a whole person – not as a diabetic or a person who happens to have high blood pressure, but as a person who needs health care,” says Ali Shropshire, clinical nurse practitioner at Stanton Road Clinic.
PCMH is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. In this concept, everyone has a personal physician – a relationship. The doctor takes care of the whole person and care is coordinated across the complex system.
“At Stanton Road Clinic, patients come to us to meet as many of their needs as possible, and then we refer out to specialists as needed,” Shropshire said. “The patients are like family, and we take into consideration the patients’ wants and wishes when we develop a care plan.”
The PCMH concept provides coordinated, comprehensive primary care services that are delivered through high-functioning patient care teams. This model aids practices in meeting the Institute for Healthcare Improvement’s Triple Aim objectives that are focused on improving the health care experience of the patient, improving the health of populations and reducing health care costs.
“The traditional medical model placed the provider in the center of the care model, where PCMH places the patient in the center, and the health care team coordinates medical services,” said Dr. Natalie Fox, director of nursing and a pediatric nurse practitioner at USA Physicians Group. “The PCMH model helps to ensure patients receive the right care when they need it.”
As part of the PCMH model, each patient will have a primary health care provider who is a member of a small team within the clinic. Each time that patient needs medical care, he or she will see the primary provider, if available. or another member of the team if the primary provider is not available. Odds are that, over time, each patient will meet with every member of the team so that he or she sees a familiar face at each visit.
Recognition as a patient-centered medical home includes other factors, as well – among them expanded access, support services and continuous quality improvement.
“We had to look at our processes and transform our practices to ensure we were operating by the PCMH standards,” Dr. Fox said.
Each of the six standards – patient-centered access, team-based care, population health management, care management and support, care coordination and care transitions, and continuous quality improvement – require written processes and documentation requirements that must be submitted to the NCQA.
“While the process is time consuming and labor intensive, it is also rewarding,” Dr. Fox added. “Not only did our quality of care improve, but our care teams also became more empowered and we improved our clinical efficiency.”
“The patient-centered medical home ensures that our patients receive the necessary care when and where they need it, and in a manner they can understand,” Beck said. “PCMH recognition provides us full credit in the ‘improvement activities’ requirement for our Merit-based Incentive Payment System (MIPS) reporting.”
The recognitions also demonstrate USA Health’s commitment to advancing medical education.
“This is an excellent opportunity for resident physicians because PCMH is the way of the future, and they are exposed to these standards during training,” Shropshire said. “It is important for our learners to understand the reformed health care delivery system so they will be able to promote the Institute for Healthcare Improvement Triple Aim – ‘better care, smarter spending and healthier people’ – in their own practices,” Dr. Fox added. “As payment models shift from fee-for-service to value-based payments, instilling the PCMH model into medical education also ensures the health care providers of tomorrow are prepared for the changing healthcare economy.”
Support services are also key to the PCMH designation. Individuals with severe chronic conditions will have access to a pharmacist, nutritionist and social worker at Stanton Road Clinic. Behavioral health is also a standard service, with all patients screened for depression.
“It’s providing thorough care under one roof,” Shropshire said. “For PCMH specifically, we attempt to decrease ER visits and hospital readmissions by identifying our top health care utilizer patients and see them more frequently to address their barriers to maintaining their health.”
USA Health is one of few centers with multiple PCMH-designated clinics. According to Dr. Fox and Shropshire, significant effort and time went into creating policies and processes to foster the PCMH model.
“The recognition was a team effort and would not have happened without great providers, nursing and clerical leadership, along with commitment from each staff member,” Dr. Fox said. “Achieving recognition does not mean practice transformation is over, as we will continue to evaluate our processes and outcomes to improve quality and clinical efficiency as part of maintaining our PCMH recognition.”