The Patient-Centered Medical Home Part II: Spring Training–Preparing to Take the Field

This article is the second of three parts.

Determination. Persistence. Ability to effect change. Enthusiasm. Commitment. These are just some of the qualities needed in someone who leads the Patient-Centered Medical Home (PCMH) charge. The path to recognition as a PCMH can take over a year, and that focuses only on the application and recognition process. True care transformation, embedding the principles of the PCMH model in the practice and seamlessly making them operational, will take even longer. If the transition is properly executed, your patients will have an improved health status and be happier, your staff will be more engaged, clinicians will be less stressed, and financial performance should improve. If you still are not convinced that the change to the PCMH model is necessary at this point, I suggest you read our first article in this series, “The Patient-Centered Medical Home: Part I—A Primer,”(1) to familiarize yourself with the basic concepts.

The roadmap to a PCMH is composed of two parallel initiatives: (1) the application process, which builds the framework for success; and (2) the care transformation process, which builds on that framework using the policies developed and puts them into practice. Both must be completed for a practice to be considered a PCMH, and there is significant overlap between the two. Further, the ability to transform is often predicated on a completed application factor (a factor is a specific item such as a report or policy). Before embarking on the application, determining readiness to start down the PCMH path is paramount. The application provides a roadmap to accomplish this.

Application Overview

When it comes to the application, there is a hierarchy within the methodology framework centered on the core concepts, then moving down to the individual requirements necessary to meet each concept. Six standards make up the central tenets of a PCMH. Each standard includes a number of elements (totaling 27 elements) that outline key requirements necessary to achieve that standard’s goal. Each element can be met by implementing specific action items (e.g., creating a report and a policy). These action items are called factors, and in total, there are 178 factors.

PCMH recognition is tiered, meaning your practice can be recognized as a level 1, 2, or 3. Each of the factors, elements, and standards adds points to the application (with a possible maximum of 100 points) Level 3, the highest level, is reserved for practices that demonstrate they have met a majority of PCMH elements by scoring over 85 points. Not every element or every factor has to be met; however, certain elements are considered “must pass” elements, and these must be met to receive recognition. Some factors are identified as “critical factors,” which are required in order to exceed a minimum number of points in a particular element. Due to the large number of factors within the application, the practice must dedicate resources to complete the many requirements.

In December 2014, Emory Clinic’s Department of Family and Preventive Medicine received recognition as a Level 3 PCMH. This group is a department of Emory Healthcare, a large academic medical center based out of Atlanta, Georgia, and home to 10 FTEs and 28 Residents. The application process took more than 12 months to complete, and the group is still in the process of fully implementing and perfecting the care transformation aspect in the clinic and ensuring that all the benefits of the PCMH model are realized. Dr. Toyosi Morgan, Director of Preventative Medicine, describes what was necessary to begin the PCMH process,

“You need a commitment of resources to [complete the application]. Resources by virtue of time commitment to actually taking time away from the clinical practice to review the work flows. There needs to be an investment in the analytics framework, such as the electronic medical records, the ability to generate reports and create those reports in such a way they can be reviewed by the providers and nurses and then used to move them into actionable changes. You need the opportunity to take a step back and look at the practice and see where the care gaps are and where the missed opportunities are and rebuild a clinical practice in a way that minimizes those missed opportunities.”

The resources Morgan discussed are necessary to develop the required application components, such as reports, policies, and other documentation.

Reports

Demonstrating the ability to run reports and act on the data is a large component of the PCMH application. A data warehouse is not a requirement for practices, but it is certainly helpful. And at the very least, many electronic medical records have report-building capability. The PCMH is not concerned with revenue cycle or financial reports, but, rather, with reports that outline and demonstrate quality of care. These reports allow patient registries to be constructed so targeted approaches to improve care can be developed and executed. Practices uncertain of whether their systems have this functionality may need to reach out to their software vendor to better understand the capabilities of their existing systems. If a practice does not have a data warehouse or an electronic health record capable of running and building reports, all is not lost; you have the ability to calculate some success rates manually.

Documentation

Written documentation is the other main requirement for the application. The written documentation outlines all the various workflows for the different factors. Before submitting the application, all documented processes must have been active for three months.

An example of written documentation is the handling of walk-in patients. For this factor, the roles and responsibilities of the staff members and physicians must be documented, with descriptions of the actions to be taken when patients walk in to the clinic seeking care. If an organization is submitting a multisite application, this written documentation must be standardized at all the different locations and actively followed at all sites.

Records or Files

Well-documented and comprehensive patient records allow providers to fully understand the patient as a whole, rather than as a disease or illness. Therefore, the National Committee for Quality Assurance (NCQA) asks to see various records or files demonstrating that certain information can be and is documented in a patient’s chart. Screenshots are used to demonstrate to the NCQA that the practice’s system functions according to the requirement. The record review workbook(2) requires a practice to manually go through a random group of patient records and prove specific factors are documented: for example the development of a care plan; acknowledgement of understanding; family history; and so on.

Application Gap Analysis

Understanding the gaps associated with a practice’s ability to complete the requirements of application involves understanding current system limitations and functionality. Knowledge surrounding how much information a practice can extract from your system will be essential in determining the timeframe required for collecting all the reports (Figure 1).

Determining system capabilities and limitations is the first step in gap analysis. Inadequate reporting functionality often can make this time consuming due to the lack of pre-built reports in the EHR system. When reports can be run successfully, it is important to understand quickly how a practice is performing relative to current goals. As an example, Standard 1C describes the importance of electronic access to health information. The second factor states that more than 5% of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. If report-building capability exists, the next important step is to see if the practice can meet these requirements. If not, rapid improvement plans must be developed to meet and exceed these thresholds. A number of these factors correspond to Meaningful Use requirements and are therefore familiar to most health systems and practices that have already completed their Meaningful Use attestations.

The second step associated with documentation is multifaceted: first, the practice will need to know what the current workflows are and whether it can meet the requirements. Secondly, it is necessary to determine whether those work flows are documented on paper or electronically. Finally, a process must be created to alter work flows to meet the requirements.

This requires a multistep approach, beginning with cataloging the current documented processes. All current processes that are not catalogued electronically should be evaluated to see if they are in place within the practice. If they are in place, they must be documented formally, and if they are not in place the processes must be developed and then implemented for at least three months before the submission of the application (Figure 2).

Care Transformation

The application is necessary to receive recognition as a PCMH. However, it is just one step toward becoming a true PCMH. The real benefit is realized during the care transformation that takes place before, during, and after the application process. Care transformation is what facilitates the improved access and quality, the decreased emergency room usage, the decreased costs, and everything else. Success in this portion of the transition requires more work and nurturing.

Culture is so important that the wrong culture will cause the transformation to fail.

The first vital question is to understand the vision of the practice. Thought must go into answering the questions “Why do we want to do this?” and “What does this mean for the patients and for us?” Having a clear, well-articulated answer to these two questions is necessary during internal communications to help achieve staff buy-in.

The second vital question is “What is the culture like in the practice?” Culture is vitally important to the success of this transformative process. Is the culture willing to embrace change? Is the focus on the patient? The care transformation process will require workflows to change, which will have an impact on all staff members, likely requiring a change in how each person performs his or her job function. The practice staff together must determine the best ways to address these issues and identify the care gaps that result from the current approach. Some staff will need to make concessions, and to do this they must first understand the practice’s vision and its commitment to make this change. Physicians need to buy in to this effort and reinforce its importance to their patients and then be willing to step back and empower the staff to take on the task of making the model operational.

Culture is so important that the wrong culture will cause the transformation to fail. The Department of Family and Preventive Medicine at Emory Clinic tried and failed to undergo the transformation a few years ago. Reshunda Redmond, Clinic Administrator, recalls the reason it didn’t work out:

It was not a culture supportive of change. [As an academic medical practice], the residency group was the dominant focus. The goal was to train and be trained and then graduate. That was the predominant focus. It was not patient-centered. Under this different leadership [physicians] weren’t as engaged.

Transparent communication during physician education sessions on the future healthcare landscape helped the physicians at Emory Clinic eventually agree they could not continue with the status quo. Morgan remembers the feeling when PCMH was brought up the second time as a potential solution:

[We realized we] needed to do something different and this seemed reasonable. There was consensus there. The challenges came with regard to what resources we needed and how to obtain those resources. A lot of primary care practices aren’t operating with huge profits. Those resources need to be created from some place of surplus or investment.

Strong clinic and physician leadership was essential in rallying the troops and getting over the initial hurdle.

Change does not occur just in the beginning, nor does it simply last during the 12 months of the application process. Workflows should constantly be reviewed, with feedback provided from the staff. This, in addition to data, will provide insight to the strengths and weaknesses of a current protocol. As a result, the current protocol may need to be changed to ensure success. This constant change may be difficult for people to handle. Therefore, reassurance, along with transparency, will be needed in addition to the constant communication that should take place during this transformation. We will review some communication strategies in Part III of this article to help ensure staff are informed and are bought into the PCMH model.

An effective medical home will have all employees working at the top of their license. Any work that can be delegated in a downward direction should be delegated to remove unnecessary burden from staff members, freeing them up for more crucial work. This change will be difficult for some people to accept—physicians will need to develop standing orders and trust their clinical staff to adhere to the policies as written; staff members will need to be able to handle a changing and evolving set of responsibilities; and the changing workflows must be accepted by the whole group, not just a subset. Thus, it is vitally important to understand the organization’s current culture and the staff’s acceptance of changing workflows when pursuing a PCMH.

In addition to a willingness to accept changing workflows, a change in how healthcare is approached is important. Medicine will have to move from a reactionary to a preventive model, and this will require the physicians to make a change. The goal is to treat people before they need to be treated, to follow up on patients who have been referred to specialists, and to be responsible for ensuring that yearly maintenance visits, shots, and evaluations are conducted routinely. This goes against what has been common practice: waiting for patients to get sick and then treating them when they decide to go to the clinic.

Primary care practices have an increased responsibility to manage the complete care of the patient through a multitude of care coordination tasks. This involves tracking and following up on lab and test results along with referring providers. Many practices struggle with this aspect due to the time and resource commitment required for successful implementation. It will be necessary to develop and maintain comanagement agreements and relationships with specialty practices. Often, additional staff may have to be hired to help due to the increased volume of work associated with proper care coordination.

Conclusion

Gap analysis is important to understand the barriers that arise when going through the PCMH transformation. If gaps are present, the practice must evaluate the difficulty and time required to overcome those gaps. Once the gaps are understood, it is possible to develop a timeline and order of prioritization for implementing the various tasks.

Once the gap analysis is completed, it is time to act! The next article in this series reviews how to efficiently complete the PCMH application and bolster care transformation within the practice. We’ll review tips from other practices and learn from their experiences.

References

1. Blubaugh S. The Patient-Centered Medical Home: Part I—a primer. J Med Pract Manage. 2016;31:346-350.

2. PCMH 2014 Record Review Workbook. www.youtube.com/watch?v=I_DwadhQ_T4&feature=youtu.be