Student Forum Key Aspects and Health Care Benefits of Patient-Centered Medical Homes Part 1 of 3 Eric Stack, Karen Kier The concept of patient-centered medical homes (PCMHs) is one of the latest efforts to provide higher quality of life for patients while aiming to reduce overall health care costs. As part of this health care reform effort, PCMHs strive to provide patient-centered, coordinated, effective, and efficient care that leads to long-term relationships with patients. The objective of this three-part series is to provide a comprehensive review of the PCMH for health care practice sites and professionals, its key features, recognition of quality programs, support and payment models from government and third-party insurers, and patient and professional benefits. Part 1 describes the history and development of PCMHs, the overall concept of the health care model, and the process that is used to recognize quality PCMHs. Because of the current weaknesses and deficiencies in the United States’ health care system, there is a definitive need for the establishment and expansion of PCMHs. Key Words: Health care reform, Medication therapy management, National Committee for Quality Assurance, Patient-centered medical home, Pharmacist. Abbreviations: ISS = Interactive Survey System, NCQA = National Committee for Quality Assurance, PCMH = Patient-centered medical home, PPC-PCMH = PhysicianPractice Connections-Patient-Centered Medical Home. Consult Pharm 2014;29:196-9.
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Introduction The concept of patient-centered medical homes (PCMHs) is one of the latest health care reform efforts aimed at providing higher quality of care for all patients while reducing overall health care costs. This model began in 2007 when several practitioner organizations worked together to define the principles of the medical home. This model not only can potentially provide an avenue for higher-quality health care services, but it also can do so at a more affordable cost for patients.1 This article, the first in a three-part series, describes the key aspects of the PCMH effort as defined by the National Committee for Quality Assurance (NCQA), a group that accredits and certifies a wide range of health care organizations. It also examines the role of PCMHs in the United States’ evolving health care system, including the Affordable Care Act, which overhauls much of the health care system and affects associated reimbursement plans.2 PCMHs offer an array of benefits to health care practices seeking to improve patient outcomes and are supported by various professional health care organizations and private third-party insurers.3 For example, PCMHs meet the objectives of the Institute for Healthcare Improvement, an independent not-for-profit organization whose goal is to improve health care. The group’s Triple Aim Theory is its three-pronged approach to optimizing health system performance.4 Overall, various PCMH models have been proven to be effective from both the patient care and economic aspects.
History In 2007, the Joint Principles of the Patient-Centered Medical Home were created by four primary care physician societies, which included the American College of Physicians, the American Academy of Family Physicians, the American Osteopathic Association, and the American Academy of Pediatrics. Since then, an additional 18 physician organizations have embraced PCMHs, as well as numerous professional organizations representing various health care professionals.5 In 2008, NCQA developed the Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) Recognition Program.4 This program
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Key Aspects of Patient-Centered Medical Homes
is an extension of a 2003 program that recognizes practices using systematic processes to enhance the quality of patient care. Updated in 2011, the program provides the current set of PCMH standards.1 Through this program, NCQA assesses primary care outpatient practices based on a list of requirements for establishing and maintaining a recognized PCMH.6 As of 2010, there were 1,506 practice sites that NCQA recognized for the PCMH program.7 For primary care clinics looking to become a recognized PCMH by NCQA, it provides an accepted set of guidelines on which a practice can be evaluated and base its health care operations.7 Overall, the PCMH recognition program has many components relating to the evolving model of health care as outlined in the Institute of Medicine’s Crossing the Quality Chasm and the “10 Simple Rules for the 21st Century Health Care System.”8
PCMH Model Overall, a PCMH is defined as a: “model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has an individual connection with a primary care clinician who leads a team that takes collective responsibility for patient care, providing for the patient’s health care needs and arranging for appropriate care with other clinicians. The medical home is intended to result in more personalized, coordinated, effective, and efficient care.”1 Each PCMH must be led by one or more independent clinicians—normally a primary care physician, but in certain states may be a physician assistant or nurse practitioner.6 A PCMH is not restricted to one building or complex, but instead is based on a health care team with available, coordinated, and integrated health care. Overall, PCMHs have been shown to advance patient health while decreasing overall health care costs, especially by reducing the amount of emergency room visits that can be handled at a primary care practice.5 PCMHs’ emphasis on long-term relationships between the clinician and patient often results in an improved continuum of care. A patientcentered approach is developed by providing adequate access to services, managing a patient’s health needs, and
coordinating further care. Therefore, NCQA recognition status demonstrates a desire by the practice site to improve patient health care.1 Pharmacists can play a vital role in the success of a PCMH and continuity of care by providing medication therapy management services and counseling between provider appointments, especially for patients with chronic disease states, complicated medication regimens, and/or undergoing a transition of care.9 PCMHs have the potential to receive reimbursement for the patient care provided.1
Application and Recognition First, the “Administrative/Business Account” is an online application for primary care practice sites seeking to become an NCQA-recognized PCMH, which involves business as well as demographic information. Only one account per organization is necessary, and all practice sites under the same organization use the same account. However, there is a separate application for each practice site. Along with the business information, the clinician data must be added to every site, and there are agreements that must be submitted electronically. The Interactive Survey System (ISS) tool is an electronic database used by practices to document achievement of the necessary standards for PCMH approval, which are then broken down into elements and specific factors (described in more detail in Part 2 of this series). The six core elements include: • Enhancing access and continuity of patient care • Identifying and managing patient populations • Planning and managing care • Providing support and community resources for a patient’s self-care • Tracking and coordinating patient care • Measuring/improving the performance of both the clinicians and practice site The ISS tool outlines the required elements for PCMH recognition and ultimately enhances the practice site’s ease of documentation.10 Primary care practice sites can decide if they are ready to apply for recognition by using the ISS tool to determine which standards they meet or need improvement.
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Student Forum For each primary care practice site beginning the process of NCQA recognition, there is a standard survey fee, with an additional fee for renewal. Pricing of the application fee is determined by the number of clinicians practicing at the medical site.11 Some practice sites have nonprimary care clinicians such as specialists, and these specific clinicians should not be included in the process of applying for PCMH recognition.10 There is also the option for an add-on or survey upgrade fee. An add-on refers to situations in which practice sites want to attempt to advance their ranking to a higher PCMH recognition level, which can be done at any point during the practice site’s present recognition period. A practice site can enhance its score by documenting specific elements onto the application. Since recognition levels indicate a practice site’s performance relating to meeting-specified standards, patients are able to look at the NCQA Recognition Directory when interested in using a PCMH practice site.1,11 The upgrade fee refers to a practice site upgrading from the 2008 to the 2011 survey tool. Furthermore, there is the option for the NCQA multisite group survey process, which occurs when there are at least three practice sites that all share the same electronic health record, staff policies, and procedures.11 Once a practice site is recognized by NCQA, the status is official for three years.1 For practice sites seeking renewal for NCQA recognition, there is a lighter load of required documentation, and the attention is focused on areas of redesign and more sophisticated areas of the program. Overall, for sites seeking either renewal or first-time recognition, there are certain elements and factors for which documentation is not required. However, practice sites selected for audits must be able to retrieve proper documentation.7 NCQA audits up to 5% of the total submissions, which occur by a review at the physician’s facility, a teleconference, and/ or via e-mail.1,10 Practice sites may be audited in both the recognition application process and in those that have already received NCQA PCMH recognization.10
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Conclusion Overall, PCMHs have been rapidly expanding in a relatively short period of time, with various health care professions endorsing both the current and potential health care benefits of the patient-centered approach. The NCQA recognition process prepares primary care practices to familiarize themselves with the required elements necessary to operate as a PCMH; these are discussed further in Part 2 of this series.
Pharmacists and Medical Homes For more information about pharmacists’ role in providing care in a patient-centered medical home, see “Medical Home 101: The Pharmacist’s Role in This Growing Patient-Centered Care Model” (Kaldy J. Consult Pharm 2010;25:468-74).
Eric Stack is a 2014 PharmD candidate, Ohio Northern University, Ada, Ohio. Karen Kier, PhD, RPh, BCPS, BCACP, is professor of clinical pharmacy and director of assessment, Pharmacy Practice Department, Ohio Northern University. For correspondence: Karen Kier, PhD, RPh, BCPS, BCACP, Pharmacy Practice Department, Ohio Northern University, Robertson-Evans 236, 525 S Main St., Ada, OH 45810; Phone 419772-2285; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.196.
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Key Aspects of Patient-Centered Medical Homes
References 1. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home 2011: Health Care That Revolves Around You. National Committee for Quality Assurance 2011. Available at http://www.ncqa. org/Portals/0/Programs/Recognition/2011PCMHbrochure_web.pdf. Accessed January 26, 2013. 2. Long A, Bailit M. Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act. Safety Net Medical Home Initiative 2010. Available at www.co.fresno.ca.us/viewdocument.aspx?id=47522. Accessed January 26, 2013. 3. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home PPC-PCMH. National Committee for Quality Assurance. Available at http://www.ncqa.org/Portals/0/PCMH%20brochure-web.pdf. Accessed January 26, 2013. 4. Institute for Healthcare Improvement. The Triple Aim: Optimizing Health, Care and Cost. Healthcare Executive 2009. Available at http://www.ihi.org/offerings/Initiatives/TripleAim/Documents/ BeasleyTripleAim_ACHEJan09.pdf. Accessed January 26, 2013. 5. Nielsen M, Langner B, Zema C et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative 2012. Available at www.pcpcc.net/guide/benefits-implementing-pcmh. Accessed January 26, 2013. 6. National Committee for Quality Assurance. NCQA Standards Workshop Patient-Centered Medical Home PCMH 2011 Part 2:
Standards 1-3. National Committee for Quality Assurance 2011. Available at http://www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/ PCMH%202011%20standards%201-3%20%20workshop_2.3.12.pdf. Accessed January 26, 2013. 7. National Committee for Quality Assurance. NCQA’s Patient-Centered Medical Home (PCMH). National Committee for Quality Assurance 2011. Available at http://www.ipfcc.org/advance/topics/PCMH_2011_ Overview_White_Paper.pdf. Accessed January 26, 2013. 8. National Committee for Quality Assurance. Standards and Guidelines for Physician Practice Connections-Patient-Centered Medical Home. National Committee for Quality Assurance 2008. Available at http://www. usafp.org/PCMH-Files/NCQA-Files/PCMH_Overview_Apr01.pdf. Accessed July 1, 2013. 9. Berdine HJ, Skomo ML. Development and integration of pharmacist clinical services into the patient-centered medical home. JAPhA 2012;52:661-7. 10. National Committee for Quality Assurance. Getting on Board PCMH. National Committee for Quality Assurance 2012. Available at http:// www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/Getting_ OnBoard_Slides_New_7.16.12.pdf. Accessed January 26, 2013. 11. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home (PCMH 2011) Recognition Program Pricing. National Committee for Quality Assurance 2011. Available at http://www.ncqa. org/Portals/0/Programs/Recognition/PCMH_2011_Pricing_Schedule(2). pdf. Accessed January 26, 2013.
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196
Introduction The concept of patient-centered medical homes (PCMHs) is one of the latest health care reform efforts aimed at providing higher quality of care for all patients while reducing overall health care costs. This model began in 2007 when several practitioner organizations worked together to define the principles of the medical home. This model not only can potentially provide an avenue for higher-quality health care services, but it also can do so at a more affordable cost for patients.1 This article, the first in a three-part series, describes the key aspects of the PCMH effort as defined by the National Committee for Quality Assurance (NCQA), a group that accredits and certifies a wide range of health care organizations. It also examines the role of PCMHs in the United States’ evolving health care system, including the Affordable Care Act, which overhauls much of the health care system and affects associated reimbursement plans.2 PCMHs offer an array of benefits to health care practices seeking to improve patient outcomes and are supported by various professional health care organizations and private third-party insurers.3 For example, PCMHs meet the objectives of the Institute for Healthcare Improvement, an independent not-for-profit organization whose goal is to improve health care. The group’s Triple Aim Theory is its three-pronged approach to optimizing health system performance.4 Overall, various PCMH models have been proven to be effective from both the patient care and economic aspects.
History In 2007, the Joint Principles of the Patient-Centered Medical Home were created by four primary care physician societies, which included the American College of Physicians, the American Academy of Family Physicians, the American Osteopathic Association, and the American Academy of Pediatrics. Since then, an additional 18 physician organizations have embraced PCMHs, as well as numerous professional organizations representing various health care professionals.5 In 2008, NCQA developed the Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) Recognition Program.4 This program
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Key Aspects of Patient-Centered Medical Homes
is an extension of a 2003 program that recognizes practices using systematic processes to enhance the quality of patient care. Updated in 2011, the program provides the current set of PCMH standards.1 Through this program, NCQA assesses primary care outpatient practices based on a list of requirements for establishing and maintaining a recognized PCMH.6 As of 2010, there were 1,506 practice sites that NCQA recognized for the PCMH program.7 For primary care clinics looking to become a recognized PCMH by NCQA, it provides an accepted set of guidelines on which a practice can be evaluated and base its health care operations.7 Overall, the PCMH recognition program has many components relating to the evolving model of health care as outlined in the Institute of Medicine’s Crossing the Quality Chasm and the “10 Simple Rules for the 21st Century Health Care System.”8
PCMH Model Overall, a PCMH is defined as a: “model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has an individual connection with a primary care clinician who leads a team that takes collective responsibility for patient care, providing for the patient’s health care needs and arranging for appropriate care with other clinicians. The medical home is intended to result in more personalized, coordinated, effective, and efficient care.”1 Each PCMH must be led by one or more independent clinicians—normally a primary care physician, but in certain states may be a physician assistant or nurse practitioner.6 A PCMH is not restricted to one building or complex, but instead is based on a health care team with available, coordinated, and integrated health care. Overall, PCMHs have been shown to advance patient health while decreasing overall health care costs, especially by reducing the amount of emergency room visits that can be handled at a primary care practice.5 PCMHs’ emphasis on long-term relationships between the clinician and patient often results in an improved continuum of care. A patientcentered approach is developed by providing adequate access to services, managing a patient’s health needs, and
coordinating further care. Therefore, NCQA recognition status demonstrates a desire by the practice site to improve patient health care.1 Pharmacists can play a vital role in the success of a PCMH and continuity of care by providing medication therapy management services and counseling between provider appointments, especially for patients with chronic disease states, complicated medication regimens, and/or undergoing a transition of care.9 PCMHs have the potential to receive reimbursement for the patient care provided.1
Application and Recognition First, the “Administrative/Business Account” is an online application for primary care practice sites seeking to become an NCQA-recognized PCMH, which involves business as well as demographic information. Only one account per organization is necessary, and all practice sites under the same organization use the same account. However, there is a separate application for each practice site. Along with the business information, the clinician data must be added to every site, and there are agreements that must be submitted electronically. The Interactive Survey System (ISS) tool is an electronic database used by practices to document achievement of the necessary standards for PCMH approval, which are then broken down into elements and specific factors (described in more detail in Part 2 of this series). The six core elements include: • Enhancing access and continuity of patient care • Identifying and managing patient populations • Planning and managing care • Providing support and community resources for a patient’s self-care • Tracking and coordinating patient care • Measuring/improving the performance of both the clinicians and practice site The ISS tool outlines the required elements for PCMH recognition and ultimately enhances the practice site’s ease of documentation.10 Primary care practice sites can decide if they are ready to apply for recognition by using the ISS tool to determine which standards they meet or need improvement.
The Consultant Pharmacist march 2014 Vol. 29, No. 3
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Student Forum For each primary care practice site beginning the process of NCQA recognition, there is a standard survey fee, with an additional fee for renewal. Pricing of the application fee is determined by the number of clinicians practicing at the medical site.11 Some practice sites have nonprimary care clinicians such as specialists, and these specific clinicians should not be included in the process of applying for PCMH recognition.10 There is also the option for an add-on or survey upgrade fee. An add-on refers to situations in which practice sites want to attempt to advance their ranking to a higher PCMH recognition level, which can be done at any point during the practice site’s present recognition period. A practice site can enhance its score by documenting specific elements onto the application. Since recognition levels indicate a practice site’s performance relating to meeting-specified standards, patients are able to look at the NCQA Recognition Directory when interested in using a PCMH practice site.1,11 The upgrade fee refers to a practice site upgrading from the 2008 to the 2011 survey tool. Furthermore, there is the option for the NCQA multisite group survey process, which occurs when there are at least three practice sites that all share the same electronic health record, staff policies, and procedures.11 Once a practice site is recognized by NCQA, the status is official for three years.1 For practice sites seeking renewal for NCQA recognition, there is a lighter load of required documentation, and the attention is focused on areas of redesign and more sophisticated areas of the program. Overall, for sites seeking either renewal or first-time recognition, there are certain elements and factors for which documentation is not required. However, practice sites selected for audits must be able to retrieve proper documentation.7 NCQA audits up to 5% of the total submissions, which occur by a review at the physician’s facility, a teleconference, and/ or via e-mail.1,10 Practice sites may be audited in both the recognition application process and in those that have already received NCQA PCMH recognization.10
198
Conclusion Overall, PCMHs have been rapidly expanding in a relatively short period of time, with various health care professions endorsing both the current and potential health care benefits of the patient-centered approach. The NCQA recognition process prepares primary care practices to familiarize themselves with the required elements necessary to operate as a PCMH; these are discussed further in Part 2 of this series.
Pharmacists and Medical Homes For more information about pharmacists’ role in providing care in a patient-centered medical home, see “Medical Home 101: The Pharmacist’s Role in This Growing Patient-Centered Care Model” (Kaldy J. Consult Pharm 2010;25:468-74).
Eric Stack is a 2014 PharmD candidate, Ohio Northern University, Ada, Ohio. Karen Kier, PhD, RPh, BCPS, BCACP, is professor of clinical pharmacy and director of assessment, Pharmacy Practice Department, Ohio Northern University. For correspondence: Karen Kier, PhD, RPh, BCPS, BCACP, Pharmacy Practice Department, Ohio Northern University, Robertson-Evans 236, 525 S Main St., Ada, OH 45810; Phone 419772-2285; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2014 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2014.196.
The Consultant Pharmacist march 2014 Vol. 29, No. 3
Key Aspects of Patient-Centered Medical Homes
References 1. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home 2011: Health Care That Revolves Around You. National Committee for Quality Assurance 2011. Available at http://www.ncqa. org/Portals/0/Programs/Recognition/2011PCMHbrochure_web.pdf. Accessed January 26, 2013. 2. Long A, Bailit M. Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act. Safety Net Medical Home Initiative 2010. Available at www.co.fresno.ca.us/viewdocument.aspx?id=47522. Accessed January 26, 2013. 3. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home PPC-PCMH. National Committee for Quality Assurance. Available at http://www.ncqa.org/Portals/0/PCMH%20brochure-web.pdf. Accessed January 26, 2013. 4. Institute for Healthcare Improvement. The Triple Aim: Optimizing Health, Care and Cost. Healthcare Executive 2009. Available at http://www.ihi.org/offerings/Initiatives/TripleAim/Documents/ BeasleyTripleAim_ACHEJan09.pdf. Accessed January 26, 2013. 5. Nielsen M, Langner B, Zema C et al. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012. Patient-Centered Primary Care Collaborative 2012. Available at www.pcpcc.net/guide/benefits-implementing-pcmh. Accessed January 26, 2013. 6. National Committee for Quality Assurance. NCQA Standards Workshop Patient-Centered Medical Home PCMH 2011 Part 2:
Standards 1-3. National Committee for Quality Assurance 2011. Available at http://www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/ PCMH%202011%20standards%201-3%20%20workshop_2.3.12.pdf. Accessed January 26, 2013. 7. National Committee for Quality Assurance. NCQA’s Patient-Centered Medical Home (PCMH). National Committee for Quality Assurance 2011. Available at http://www.ipfcc.org/advance/topics/PCMH_2011_ Overview_White_Paper.pdf. Accessed January 26, 2013. 8. National Committee for Quality Assurance. Standards and Guidelines for Physician Practice Connections-Patient-Centered Medical Home. National Committee for Quality Assurance 2008. Available at http://www. usafp.org/PCMH-Files/NCQA-Files/PCMH_Overview_Apr01.pdf. Accessed July 1, 2013. 9. Berdine HJ, Skomo ML. Development and integration of pharmacist clinical services into the patient-centered medical home. JAPhA 2012;52:661-7. 10. National Committee for Quality Assurance. Getting on Board PCMH. National Committee for Quality Assurance 2012. Available at http:// www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/Getting_ OnBoard_Slides_New_7.16.12.pdf. Accessed January 26, 2013. 11. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home (PCMH 2011) Recognition Program Pricing. National Committee for Quality Assurance 2011. Available at http://www.ncqa. org/Portals/0/Programs/Recognition/PCMH_2011_Pricing_Schedule(2). pdf. Accessed January 26, 2013.
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