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Tuesday Nov 11, 2014

So You've Achieved PCMH Recognition. Now What?

Last year, my health care system -- which has seven hospitals in the Kansas City, Mo., metro area -- received National Committee for Quality Assurance (NCQA) Level 3 patient-centered medical home (PCMH) recognition for 12 of its primary care locations. We set an ambitious goal and realized it within two years.

Now, having met all the NCQA's PCMH criteria, what happens next? Is that the end of the story?

  Photo by Dean Shepard

 I talked with more than 200 of my health system's physicians during our patient-centered medical home summit. Twelve of our 14 primary care locations have earned National Committee for Quality Assurance (NCQA) Level 3 PCMH recognition.

For us, it's not. The two remaining primary care locations in our system are now starting the PCMH process. For the other 12, we're continuing to transform our practices to enhance care. One example of that ongoing transformation is the new electronic health records system being implemented across all our locations. The change will enhance our ability to manage population health because an upgraded registry function will allow us to better track and manage patients with chronic diseases such as diabetes.

Before we began our path to PCMH, we didn't have a registry at all. We didn't know how many patients with diabetes we had, let alone how many needed additional care. Now we can be proactive, rather than reactive, and we are establishing protocols for reaching out to patients when appropriate.

Team-based care will help us get this done. A year ago, care coordinators didn't exist in our health system, but now most of our primary care locations have one, and we are in the process of hiring more. This is expected to improve care transitions.

To implement this kind of sweeping change, buy-in from physicians and staff is extremely important. I've been encouraged to see that our system's subspecialists are equally enthused and intrigued about how the changes we're making can improve care. They have been eager to learn how we can work together to enhance care coordination.

In fact, we recently brought PCMH advocates Paul Grundy, M.D., M.P.H., and John Bender, M.D., to Kansas City to share their insights. More than 200 of our physicians -- both primary care and subspecialty physicians -- turned out for a PCMH summit.

Grundy, who is IBM's director of global health care transformation and founding president of the Patient-Centered Primary Care Collaborative, encouraged us to see the big picture and embrace it. Specifically, he stressed that managing data is critical in the PCMH because it allows you to manage populations and perform chronic disease management.

Bender, CEO and medical director of Miramont Family Medicine in Fort Collins, Colo., shared the story of how transforming his practice made it more efficient and more profitable and decreased emergency department visits, admission rates and readmission rates.

In short, we are preparing for the future of primary care delivery by utilizing data and exploring new and emerging technologies, while also maintaining our relationships with patients.

If you are actively transitioning your practice to the PCMH model, or simply pondering how to get started down the path to improving patient outcomes, the AAFP has resources that can help. Check out the new set of PCMH checklists and the PCMH Planner, which each reflect three levels of improvement work that can help you find ideas for what to do next, no matter where you are in your practice transformation work.

Michael Munger, M.D., is a member of the AAFP Board of Directors.


Posted at 04:54PM Nov 11, 2014 by Michael Munger, M.D.

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