The Patient-Centered Medical Home
The Patient-Centered Medical Home (PCMH) initiative is a comprehensive approach to primary care that facilitates a partnership between patients and their primary care physician (PCP), enabling physicians to better coordinate patients’ care.
Physicians need to be involved in this managed care provider initiative because reimbursement models are beginning to focus on PCMH. Recognized providers can receive a per-member, per-month care coordinator fee from some managed care plans. Other models offer a share in the savings generated by reducing the medical costs of certain populations of patient with chronic conditions like diabetes and CHF.
Several accrediting bodies exist, but Meritas Health chose to be recognized through the National Committee for Quality Assurance (NCQA). The process is rigorous and Meritas Health offices spent a year going through the recognition process. In all, nine Meritas Health primary care physician clinics achieved the highest level of recognition - level 3.
The recognition requirements include developing streamlined processes and workflow and identifying and training staff to meet the NCQA criteria for application submission. A key area is coordinating patient care for those transitioning from the hospital to home. Meritas Health offices now have a clear process to reach patients within 48 hours of discharge to schedule a follow-up appointment with their PCP within 5-7 days. Each office also has a working relationship with North Kansas City Hospital emergency physicians and hospitalists. The overarching goal is reducing readmissions.
The next phase involves population health management. If high-risk patients, including new onset diabetes and CHF, can be identified, they can be educated about the disease, taught how to overcome barriers to care, and learn self-care management.
All of these efforts are part of the Triple Aim healthcare focus of:
- Improving patient health
- Creating better healthcare experiences for patients
- Reducing costs
Dann Fredrickson, MD
Dann Fredrickson, MD, with Meritas Health Briarcliff says, “The PCMH recognition process teaches you to provide coordinated patient care in a very effective manner. It has made our practice more patient-responsive and better connected with specialists.” Meritas Health Briarcliff receives a PCP Census report from North Kansas City Hospital, allowing Meritas Health to immediately connect with patients upon discharge to schedule follow-up appointments, order home health care and manage medications. By helping to coordinate care, patients experience fewer readmissions and Meritas Health delivers on the medical home concept.
For a background on PCMH, download a white paper from NCQA.
To learn more, call 816-691-5289.