This module will provide recommendations for PCMH, focusing on these core areas:
PATIENT-CENTERED CARE
Do you have processes to ensure patients’ access to care?
Same-day appointments
Extended hours for access to care
Physician access to the medical chart 24/7 to inform care decisions
Ability for patients to select their own physician
Utilization of secure email for communication with patients
Web portal for patients to request Rx refills, schedule appointments, etc.
Procedures to accommodate patients’ barriers to care (including transportation, physical, and cognitive barriers)
Linguistically and culturally appropriate services
Do you engage patients in shared decision-making?
Discuss treatment options in an unbiased way
Consider patients’ health goals and priorities
Provide patients with condition-specific decision aids
Have decision-making discussions with patients after they have reviewed decision aids
Record patient preferences and ensure follow through on decisions
Does your practice support patient self-management?
Assess patient and caregiver self-management abilities
Utilize motivational interviewing to coach patients
Consider home monitoring of patients’ chronic conditions
Engage family and caregivers in care plan
Offer health coach support
Do you assess and improve your patients’ experience of care?
Conduct patient satisfaction surveys on a regular basis
Establish a patient advisory panel to guide practice and quality improvement activities
Conduct patient focus groups when needed
QUALITY CARE
Do you and your staff initiate a culture of improvement?
Incorporate quality improvement into daily work
Establish core performance measures
Collect and analyze data for better clinical management and efficiencies
Discuss best practices and ways to improve
Do you utilize risk-stratified care management principles to manage your patient population?
Utilize a methodology to identify each patient’s risk status
Develop and update personalized care plans
Include planned-care visits for chronic conditions and preventive services
Provide intensive care management for high-risk patients
Use tools to track patient populations by risk category
Do you incorporate patient safety into your clinic practice?
Assess patient safety in your office
Reconcile patient medications at each visit and post-hospitalization
Have processes in place to report and address errors
Do you coordinate care across the medical neighborhood?
Create an informed care team to oversee continuity of care
Manage care transitions and build linkages to community-based resources
Coordinate and monitor exchanges of information with specialists and care facilities
Evaluate a care transition process
Do you incorporate quality assurance into on-site laboratory testing?
Possess a current CLIA ’88 license for the appropriate level of testing performed
Register with COLA or other approved accreditation agency
Participate in an approved proficiency testing program, e.g. AAFP-PT
Conduct competency assessment for staff performing laboratory testing
Follow the guidelines for Good Laboratory Practice provided by the Centers for Disease Control and Prevention
PRACTICE ORGANIZATION
Do you have a staffing model and practice environment that supports a PCMH?
Personal physician that leads the team to coordinate efficient patient care
Utilize team-based care to meet your patients’ overall health care needs
Defined roles for team members that encourage staff to perform at the highest level
Flexible staffing schedules and cross-trained staff members to improve access
Health coach and care coordination functions
Patient-friendly environment that accommodates special needs
Do you embrace a culture of change in your medical practice?
Establish a PCMH leadership team to plan the transformation process
Develop a timeline for PCMH implementation and monitor progress
Engage all team members in a shared vision
Value each team member by involving them in the change management process
Provide staff education and training opportunities to support patient-centered care
Do you have a disciplined financial management approach?
Budget and forecast for the future, utilizing cost-benefit analysis
Manage cash flow and seek revenue-enhancing opportunities for your practice
Optimize coding and billing procedures
Contract and negotiate with payers from an informed position
HEALTH INFORMATION TECHNOLOGY
Have you considered these attributes in your EHR system?
Population health management through patient registries
Proactive health management of each patient
Pre-built and customized reports for quality measures
Do you utilize evidence-based clinical decision support tools?
Point-of-care answers to clinical questions
Evidence-based data collection, documentation, and order sets
Clinical terminology and coding tools (ICD, CPT, SNOMED)
Pre-built and customized point-of-care alerts and reminders
Is your practice digitally connected to the medical neighborhood?
Health information exchanges
Secure messaging with patients and health professionals
Electronic medication and diagnostic ordering/management
Consult/referral management and follow-up communications
Do you have a sound technology infrastructure in place?
Secure user access, patient consent, and data breach protocols
Compatibility with multiple device types (desktop, laptop, tablet, smart phone, etc.)
Proven processes for system updates and full data recovery
PCMH Tips & Recommendations.
An innovative incentive program through BCBSM that brings together physician organizations from across Michigan, to encourage information sharing about various aspects of health care. Program participants, including both primary care physicians and specialists, collaborate on initiatives designed to improve the health care system in the state.
An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.
An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.
An organization that is 50% owned by physicians and 50% owned by the Health System to negotiate payer contracts, assist with health plan enrollment, and provide guidance and support in mutual interests that promote evidence based care and overall well being of their customers "the patient".
Twice a year (summer and winter) BCBSM requires PO/PHO to conduct assessments for PGIP participating offices which include review of office demographic information, office technology and PCMH initiative implantation within the office. This data is linked to PCMH nomination, PCMH designations and PGIP incentive monies.
The identification of a practice within the PGIP program.
An office in PCMH nomination status is requesting review by BCBSM for PCMH Designation. An office can be nominated through their PGIP participating PO/PHO during the BCBSM Winter SRD submission.
Total number of "current" patients in the practice.
Total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past
Claim payments based on quality and utilization scoring determined by the health plan. (Quality based payment structure)