Patient-Centered Medical Home (PCMH) is a model of primary health care that many believe can improve health care in the U.S. by transforming how primary care is organized and delivered. The Health Resources and Services Administration (HRSA) supports and encourages all Section 330 funded health centers to become a recognized or accredited PCMH. CHAMPS has gathered the following information and resources to assist CHCs in understanding and becoming PCMHs. This webpage is designed to aid CHCs who are brand new to PCMH, those who have started the process of becoming a PCMH, and those who have already applied to become a recognized/accredited PCMH and require additional tools to successfully complete the process.
Please click or scroll down for:
Definition and Goals of PCMH
PCMH Recognition/Accreditation
First Steps in Becoming a Recognized/Accredited PCMH
Self Assessment Tools for Determining PCMH Readiness
Tools for Building a PCMH
Templates and Samples of PCMH Policy and Procedure
PCMH Demonstration Projects, Initiatives, and Pilot Projects
Education and Training on PCMH
Reports and Articles on PCMH
PCMH Consultation Services
Patient Satisfaction/Experience Surveys and Patient Activation/Engagement Resources
DEFINITION AND GOALS OF PCMH
A Patient-Centered Medical Home (PCMH) is a model of primary health care that puts the patient at the center of health care. The definition of PCMH varies among the many agencies and organizations involved with PCMH development in the U.S. Following are definitions from three organizations.
American Academy of Family Physicians (AAFP)
A patient-center medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute, and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes.
American Academy of Pediatrics (AAP)
AAP developed the medical home model for delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth, including children and youth with special health care needs.
Agency for Healthcare Research and Quality (AHRQ)
The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, AHRQ defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes: patient-centered care; comprehensive care; coordinated care; superb access to care; a system-based approach to quality and safety.
Although various organizations differ on the exact definition of a PCMH most agree that PCMH is a model of primary care that encompasses at least some or all of the following functions and attributes (listed in alphabetical order):
- Access to Care
- Comprehensive Care
- Coordinated Care
- Evidence-based Care
- Patient-centered Care
- Payment Structures that Recognize the Value of Primary Care
- Quality Care
- Safe Care
- Systems-based Approach to Care
- Team-based Care
Joint Principles of the Patient-Centered Medical Home was issued by AAFP, AAP, ACP, and AOA in March 2007 and is available in the following document:
www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint2011.pdf
The principles of PCMH have evolved since the issuance of the Joint Principles of the Patient-Centered Medical Home in 2007. One significant change, at the urging of community health centers, is that nurse practitioners, not just physicians, are now recognized as primary care clinicians in a medical home.
PCMH RECOGNITION/ACCREDITATION
Health centers can become a PCMH by obtaining PCMH recognition or accreditation from one of the following three programs:
Accreditation Association for Ambulatory Health Care (AAAHC)
www.aaahc.org/accreditation/community-health-centers
National Committee for Quality Assurance (NCQA)
www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh
The Joint Commission (TJC)
www.jointcommission.org/accreditation/pchi.aspx
Each of these recognition/accreditation programs has a tool for completing the process, as well as educational programs.
The document Federal Patient-Centered Medical Home (PCMH) Collaborative, Catalogue of Federal PCMH Activities as of March 2011 provides an overview of HRSA’s current strategic goals, areas of activity, pilot programs, and technical assistance related to PCMH.
HRSA’s Accreditation and PCMH Recognition Initiative provides resources for health centers to achieve PCMH recognition. Health centers must complete a Notice of Intent (NOI) to HRSA to receive HRSA support. The NOI will be processed and reviewed for organizational readiness to undertake the PCMH survey review process.
The HRSA Program Assistance Letter (PAL) 2022-04 describes the HRSA Accreditation and PCMH Recognition Initiative and outlines the process and requirements for applying for ambulatory health care accreditation and/or PCMH recognition. The PAL extends support for PCMH recognition to health center program look-alikes (LALs).
On March 8, 2011, the AAP, AAFP, ACP, and AOA released Guidelines for Patient-Centered Medical Home Recognition Programs. The new guidelines build on the Joint Principles adopted in 2007 (see above). Included are 13 guidelines that describe important elements considered essential for effective PCMH recognition programs.
NCQA also offers the following recognition programs in addition to its PCMH Recognition Program:
Back Pain Recognition Program
Diabetes Recognition Program
Heart/Stroke Recognition Program
Patient-Centered Connected Care™
FIRST STEPS IN BECOMING A RECOGNIZED/ACCREDITED PCMH
There are many resources available to health centers desiring to become a recognized or accredited PCMH. There are four basic steps in starting the process of becoming a PCMH:
1. Become Aware
Become aware of the PCMH model and the various recognition/accreditation programs available. You will find information about the PCMH model, recognition/accreditation, and many other resources on this webpage. Find out if your regional/state primary care association (PCA) has any PCMH collaborative or learning team activities that your health center may participate in. Most PCAs are offering training and/or technical assistance on becoming a recognized/accredited PCMH. You may also want to become aware of the various consulting organizations that can help your health center walk through the process of becoming a PCMH (see the PCMH Consulting Services section below). Many CHCs and PCAs are hiring consultants to help them through the PCMH process.
2. Assess Your Readiness
Every health center should perform a basic assessment of readiness before applying to a PCMH recognition or accreditation program. There are several tools available to assess your health centers readiness and are listed in the Self-Assessment Tools for Determining PCMH Readiness section below.
3. Choose a Recognition/Accreditation Program and Necessary Support Services
Decide which recognition/accreditation program will best fit your health center. Depending on which program you choose, you may also need to decide which level and year of certification you would like to aim for. Criteria for choosing a recognition/accreditation program include the following: Medicaid and/or Medicare reimbursement and incentives in your state that may be tied to a specific recognition/accreditation program; HRSA support and assistance for each program; applicability to frontier, rural, and/or isolated areas; accreditation that your health center already holds or may be applying for. This is also a good time to determine if you will participate in any collaborative or learning team activities, and/or if you will hire a consultant to help you through the process.
4. Prepare for a Rigorous Process and Form a Core Team
It often takes six or more dedicated months for a health center to complete a PCMH application process. There are usually many systems, processes, policies, and teams that a health center will need to develop to pass a PCMH program. Prepare your entire health center for this process and form a core team that will be committed to your health center gaining PCMH status.
SELF-ASSESSMENT TOOLS FOR DETERMINING PCMH READINESS
There are tools available at no cost that CHCs can use to determine if they are ready to embark on the recognition/accreditation process of becoming a PCMH. Following are a few of the self-assessment tools available.
Assessing and Increasing Readiness for Patient-Centered Medical Home Implementation
www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf72512
Robert Wood Johnson Foundation
Evaluation summary prepared under Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) initiative
Patient-Centered Medical Home Assessment (PCMH-A), Public Copy
www.safetynetmedicalhome.org/sites/default/files/PCMH-A.pdf
MacColl Institute for Healthcare Innovation
Survey designed to help practices move toward state-of-the-art in delivering PCMH care by using results from the survey to identify areas for improvement
TOOLS FOR BUILDING A PCMH
Building Your Medical Home Toolkit
www.pediatricmedhome.org
National Center for Medical Home Implementation, American Academy of Pediatrics (AAP)
Free toolkit that supports development and/or improvement of a pediatric medical home by preparing practices to apply for and potentially meet the NCQA recognition requirements, including a crosswalk between the toolkit building blocks and the NCQA “must pass” elements
Creating a Place for Care: Fostering Alignment and Eliminating Barriers in the Patient-Centered Medical Home
2016 Resource
Capital Link
Provides health centers with insight on how to respond to and reflect the unique needs and preferences of the patients they serve in order to align their facility with their process of care and the people they support
Crosswalk – NCQA 2014 PCMH – HRSA 19 Requirements – Meaningful Use
2014 Crosswalk
P.M. Talbot, NCQA PCMH CCE
Compares NCQA 2014 PCMH recognition standards, HRSA 19 requirements, and Meaningful Use requirements to help CHCs plan, organize and implement processes that satisfy requirements for multiple purposes
Developing an Organizational Culture that Sustains the Patient-Centered Medical Home
2016 Resource
Capital Link
Examines the cultural challenges and successes health centers face in sustaining the PCMH model of primary care delivery. It offers considerations for enhancing the patient, family, and staff experience and suggests flexible organizational structures to support team-based care delivery
Fostering Partnership and Teamwork in the Pediatric Medical Home Video Series
www.youtube.com/watch?v=T6sOvQsmsk&feature=c4-overview&list=UUulrbslufMIcXUghyBuZQpw
www.youtube.com/watch?v=BXRZsrnc&aQ&feature=c4-overview&list=UUulrbs.ufMIcXUghyBuZQpw
www.youtube.com/watch?v=P9M6z3P8GwM&list=UUurlrbslufMIcXUghBuZQpw
National Center for Medical Home Implementation
A “How To” Video Series including Part 1 Team Huddles, Part 2 Family Advisory Groups, and Part 3 Care Partnership Support
Health IT Success Stories
www.youtube.com/watch?v=MEBPLclwRoc&list=PLgYydErB9VCc_Wc804kKCEtK4tjpU3kc3
www.youtube.com/watch?v=bP4iRjCMsk8&&list=PLgYydErB9VCc_Wc804kKCEtK4tjpU3kc3
Agency for Healthcare Research and Quality (AHRQ)
Best practice, quality improvement programs shown on video including Electronic Standing Orders Empower Medical Staff and Improve Delivery of Care, and Improving Care Transitions for Patients with Complex Health Needs through Decision Support
Implementation Guide Series by Change Concept
www.safetynetmedicalhome.org/resources-tools/all-resources
Safety Net Medical Home Initiative
Guides and tools based on the experience of the 65 CHC sites that participated in the Safety Net Medical Home Initiative, by change concepts including Empanelment, Team-Based Healing Relationships, Patient-Centered Interactions, Engaged Leadership, QI Strategy, Enhanced Access, Care Coordination, and Organized, Evidence Based Care
Optimizing the Care Team Tool and The Evidence Base for SNMHI (Safety Net Medical Home Initiative) Change Concepts
www.champsonline.org/Events/DistanceLearning/Library.html#vol31-33
Community Health Association of Mountain/Plains States (CHAMPS)
Handout and follow-up document for the webcast Patient Care Teams: Transforming the Primary Care Practice presented in June 2013
Patient Visit Redesign, How to Start
www.patientvisitredesign.com/how-to-start
Patient Visit Redesign
Tools to guide health centers through patient visit redesign including step-by-step guides, visit tracking toolkit, visit mapping toolkit, and baseline data toolkit
PCMH Resource Center
www.pcmh.ahrq.gov/portal/server.pt/community/pcmh_home/1483
Agency for Healthcare Research and Quality (AHRQ)
Resource center provides a definition and evidence for PCMH including papers, briefs, and evaluation tools as well as resources for implementing PCMH
TEMPLATES/SAMPLES OF PCMH POLICIES AND PROCEDURES
To view and download samples of policies/procedures and PCMH recognition documentation, click on this CHAMPS webpage:
champsonline.org/resources/quality-improvement-resources/pcmh-information-and-resources/pcmh-policies-and-procedure-documents
Note: If your health center has any policies, procedures, or other documents to share that would help other Region VIII CHCs in adopting PCMH standards, please contact the CHAMPS Clinical Quality Improvement Director.
PCMH DEMONSTRATION PROJECTS, INITIATIVES, AND PILOT PROJECTS
Comprehensive Primary Care Initiative
cms.gov/priorities/innovation/innovation-models/comprehensive-Primary-Care-Initiative
Centers for Medicare & Medicaid (CMS), Center for Medicare and Medicaid Innovation
CMS initiative, announced September 28, 2011, will foster collaboration between public and private health care payers to strengthen primary care by testing a service delivery model, which includes risk-stratified care management, access and continuity, planned care, patient and caregiver engagement, and coordination of care, and by testing a payment model that will include a case management fee paid to selected primary care practices
Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Project
innovation.cms.gov/initiatives/FQHCs
CMS
Demonstration project operated by CMS in partnership with HRSA aims to show how the PCMH model can improve quality of care, promote better health, and lower costs by helping FQHCs invest in patient care and infrastructure as described in the following news release
Patient-Centered Outcomes Research Institute (PCORI)
www.pcori.org/about
Created to conduct research to provide information about best available evidence to help patient and providers make more informed decsions through research funding opportunities which are posted on the following webpage
www.pcori.org/funding-opportunities
Safety Net Medical Home Initiative
www.qhmedicalhome.org/safety-net/index.cfm
Commonwealth Fund, Qualis Health, and MacColl Institute
Five-year demonstration project initiated in 2008 to assist safety net primary care clinics in becoming high-performing PCMHs through partnerships between safety net providers and community stakeholders with five Regional Coordinating Centers being selected to participate with each including 12-15 safety net clinics in their area:
- Colorado Community Health Network
- Executive Office of Health and Human Services & Massachusetts League of Community Health Centers
- Oregon Primary Care Association and CareOregon
- Pittsburgh Regional Health Initiative
State Pilot Projects in the U.S.
www.pcpcc.org
Patient-Centered Primary Care Collaborative (PCPCC)
Listing of state PCMH projects, in safety net and multi-payer sites, across the U.S. listed by project, state, and start date
EDUCATION AND TRAINING ON PCMH
Archived Webinars
www.pcpcc.org/webinars
Patient-Centered Primary Care Collaborative (PCPCC)
Free webinar replays and slides for a multitude of presentations on PCMH including infrastructure, approaches to coordinated care, health information technology, behavioral health integration, training the workforce, and a PCPCC website walkthrough
Change Concepts
www.qhmedicalhome.org/safety-net/change-concepts.cfm
Qualis Health
Free guides, slide presentations, and videos on eight change concepts including Empanelment, Team-Based Care, Patient-Centered Interactions, Engaged Leadership, QI Strategy, Enhanced Access, Care Coordination, and Organized Evidence Based Care
NCQA Recognition Training Programs
www.ncqa.org/tabid/109/Default.aspx
NCQA
Free links to slide presentations including Getting On Board, Standards 1-3, and Standards 4-6 presented by NCQA
REPORTS/ARTICLES ON PCMH
Evaluation of CMS’ FQHC APCP Demonstration, Final First Annual Report
innovation.cms.gov/Files/reports/FQHCEvalRpt.pdf
Centers for Medicare & Medicaid Services (CMS)
February 2015
The Evidence Base for SNMHI (Safety Net Medical Home Initiative) Change Concepts
www.champsonline.org/assets/files/Events/DistanceDocuments/SNMHI_evidence_base_13-0211.pdf
Safety Net Medical Home Initiative
February 2013
Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012
www.pcpcc.org/guide/benefits-implementing-primary-care-medical-home
Patient-Centered Primary Care Collaborative (PCPCC)
2012
Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details
www.urban.org/sites/default/files/publication/24956/412338-Patient-Centered-Medical-Home-Recognition-Tools-A-Comparison-of-Ten-Surveys-Content-and-Operational-Details.PDF
The Urban Institute
March 2012
Results from 2010-11 Readiness for Meaningful Use of HIT and Patient-Centered Medical Home Recognition Survey
www.rchnfoundation.org/?p=905
Geiger Gibson/RCHN Community Health Foundation Research Collaborative, Policy Research Brief #27
November 3, 2011
Developing Federally Qualified Health Centers into Community Networks to Improve State Primary Care Delivery Systems
www.commonwealthfund.org/publications/fund-reports/2011/may/developing-federally-qualified-health-centers-community-networks
The Commonwealth Fund
May 2011
Community-Centered Health Homes: Bridging the Gap Between Health Services and Community Prevention
www.preventioninstitute.org/component/jlibrary/article/id-298/127.html
Prevention Institute
February 2011
Family Medicine: Preparing for a High-Performance Health Care System
www.jabfm.org/content/23/Supplement/S11.full
K. Davis, PhD, and K. Stremikis, MPP, JABFM, Vol. 23 Supplement
March-April 2010
Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home
www.annfammed.org/cgi/content/abstract/8/Suppl_1/S2
K. C. Stange, MD, PhD, et al., Annals of Family Medicine, Vol. 8, Supplement 1
2010
Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home
www.annfammed.org/cgi/reprint/7/3/254
P. A. Nutting, MD, MSPH, et al., Annals of Family Medicine, Vol. 7, No. 3
May/June 2009
Proof in Practice
www.pcpcc.org/guide/proof-practice
Patient-Centered Primary Care Collaborative (PCPCC)
2009
PCMH CONSULTATION SERVICES
Please note, CHAMPS does not endorse any of the following consultation services. This listing contains services that are being utilized by CHCs and private primary care practices throughout the nation. It is wise when considering a consultation service to inquire about other similar clients and ask to speak to those clients about the work performed and the level of satisfaction.
Arcadia Solutions
www.arcadiasolutions.com
HealthTeamWorks
www.healthteamworks.org/ncqa-recognition-consulting
Phytel
www3.phytel.com
Primary Care Development Corporation (PCDC)
www.pcdc.org
Qualis Health
www.qhmedicalhome.org
Quality First Healthcare Consulting, Inc. (QFHC)
www.qfhc.com
Patient Satisfaction/Experience Surveys and Patient Activation/Engagement Resources
To view information about patient satisfaction/experience surveys and patient activation/engagement click on the following CHAMPS webpage:
champsonline.org/resources/quality-improvement-resources/pcmh-information-and-resources/patient-satisfactionexperience-surveys-and-patient-activationengagement-resources
Note: If your health center has any patient satisfaction/experience surveys or other documents to share, that would help Region VIII health centers implement patient satisfaction/experience surveys and/or achieve greater patient activation/engagement, please contact the CHAMPS Clinical Quality Improvement Director.