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Home > Disease Management
Principles of a Patient-Centered Practice: Medical Home Guidelines for Staffing, Recognition and Evidence-Based Care
Principles of a Patient-Centered Practice: Medical Home Guidelines for Staffing, Recognition and Evidence-Based Care
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The transformation of a physician practice to a patient-centered medical home (PCMH) is a carefully planned process — one that starts with a culture change on the part of its doctors, staff, patients and payors and includes many practical adjustments to staffing, scheduling, patient outreach and care management so that the PCMH practice will be adequately recognized and reimbursed for its patient-centered efforts.

Principles of a Patient-Centered Practice: Medical Home Guidelines for Staffing, Recognition and Evidence-Based Care delivers essential lessons in a practice-wide redesign from organizations that have already completed the transformation — including two of the top 10 commercial health plans for 2009-2010 as ranked by the National Committee for Quality Assurance (NCQA) and the US News Media Group and a Level III NCQA-recognized medical home.

Filled with suggestions for redefining care team roles, redesigning workflow, addressing provider and staff expectations, infusing the practice with a supporting backbone of technology, and improving the patient experience, this 70-page resource is a roadmap for organizations seeking to attain the seven hallmarks of patient-centered care: a personal physician, a physician-directed practice, a whole person approach, coordinated and integrated care, quality and safety, enhanced access and a payment structure that reflects the contributions of the PCMH.

Practices poised to pursue NCQA recognition will find a detailed approach to the nine domains of the NCQA medical home scoring tool, with special emphasis on the delivery of evidence-based care.

In this 70-page special report, get details on the following programs:

  • The staffing model from Group Health Cooperative not only has the industry referring to the health system as a "model for healthcare reform" but also reduced preventable hospitalizations by 11 percent, ER visits by 29 percent and in-person visits by 6 percent, according to results published in a 2009 issue of the American Journal of Managed Care. Michael Erikson, Group Health's vice president of primary care services, walks through the Wisconsin-based cooperative's primary care practice redesign, retooled staffing models and program rollout tips. Group Health Cooperative was among the top 10 commercial health plans for 2009-2010 as ranked by the NCQA and U.S. News Media Group.

  • Drawing upon her consulting roles in several recent medical home pilots in the Northwest, Barbara Wall, president of Hagen Wall Consulting, shares straightforward tips and tools for workflow redesign that serve as a checklist for practice transformation and receive high marks from physicians, staff and consumers alike for the overall patient experience.

  • In 2008, Grand Valley Health Plan was the first in Michigan to earn NCQA PCMH recognition and is also in the top 10 NCQA-ranked commercial health plans for 2009-2010. Dr. James Kerby, vice president of medical affairs, and Barbara Luskin, quality manager at Grand Valley Health Plan, walk through the nine domains of NCQA's Physician Practice Connections® - Patient-Centered Medical Home™ — tool. They chart the daily workflow changes and processes that need to be in place for patient access, communication, education and tracking, care management, performance reporting and improvement and the adoption and implementation of evidence-based guidelines, one of the more challenging aspects of recognition for most practices.

  • Providing more detail on the delivery of evidence-based care from its Level III NCQA medical home is Dr. Richard Baron, president and CMO of Greenhouse Internists. Dr. Baron describes how the five-physician practice overcame the challenges associated with following evidence-based guidelines for each patient — from working with physicians on documentation, staff training and work flow redesign to using the data to improve practice performance. He defines the roles of technology, staff, patients and doctors in the delivery of evidence-based care.

Table of Contents

  • Group Health Cooperative Medical Home Staffing Model
    • Six Principles of the Group Health Medical Home Pilot
    • Call Management and Virtual Medicine Practices
    • Pre-Visit Preparations
    • Care Team Roles
    • Results from the One-Year Study
    • Impact on ER, Hospital and Urgent Care Utilization
  • Team-Based Model for Practice Transformation: Improving the Patient Experience
    • Drafting the Practice Team
    • Dynamics of Team-Based Care
    • New Roles for the Practice
    • Practice Support Tools
    • Tips for Patient Outreach and Recall
    • Gauging Patient Satisfaction
  • Grand Valley Health Plan's Road to NCQA Medical Recognition
    • Standard 1: Access and Communication
    • Standard 2: Patient Tracking and Registry
    • Standard 3: Care Management
    • Standard 4: Patient Self-Management Support
    • Standard 5: E-Prescribing
    • Standard 6: Test Tracking
    • Standard 7: Referral Tracking
    • Standard 8: Performance Reporting
    • Standard 9: Advanced Communication
    • NCQA Scoring Levels
    • Developing a Practice Culture to Support the PCMH
  • Greenhouse Internists' Techniques and Tools to Support Evidence-Based Guidelines
    • Technology in the Medical Home
    • Changing Expectations of Staff
    • Moving Patients Toward Self-Management
    • Cognitive Shift for Doctors
    • Some Greenhouse Examples
    • Money Models That Support Evidence-Based Delivery
  • Q&A: Ask the Experts
    • Distinguishing Referral Types
    • Moving Group Health Model to FFS Environment
    • Educating Group Health Patients about New Care Delivery Models
    • Setting Goals with Group Health Patients
    • Resources to Support Practice Transformation
    • The Co-Op as Model in Healthcare Reform
    • Frequency of Contact with Practice Coach
    • Scrubbing the Appointment Calendar
    • Structuring Reimbursement for Care Management
    • Tracking Patient Interactions with the Care Team
    • Measuring Patient Engagement
    • Administering Patient Satisfaction Surveys
    • Impact of PCMH on Utilization and Compliance
    • Optimal Patient Education Tools
    • Best Practices for Medical Home Physician Practices
    • Measuring Patient Experience, Satisfaction and Clinical Outcomes
    • Selecting Chronic Conditions for Tracking
    • Measuring Compliance
    • Measuring Third Available Appointment
    • Where to Begin the Practice Transformation
    • EMR Specifications
    • Registry Software
    • Time Frame for NCQA Data Submission
    • Benchmarks for Medical Home Care Management
    • Enforcing and Measuring Evidence-Based Guidelines
    • Engaging Patients in Evidence-Based Care
    • Referrals in Integrated Delivery Systems
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: May 2010
Number of Pages: 60
ISBN 10: 1-936186-15-2 (Print version); 1-936186-16-0 (PDF version)
ISBN 13: 978-1-936186-15-0 (Print version); 978-1-936186-16-7 (PDF version)
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VP Clinical Risk Management
Principles of a Patient Centered Practice: Medical Guidelines for Staffing, Recognition and Evidence Based Care
Reviewed by: Lucille Soltesz from West Palm Beach Fl 33401. on 11/15/2010

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