How Chapters are Leading the Way

The California chapter developed an online PCMH Resource Center that we envision as a go-to place for physicians interested in learning more about the model and for practices interested in transforming. At the center of this site is a link to our Health Information Technology toolkit, with a variety of tools to help physicians adopt the HIT that is an essential part of the PCMH model.

We have aggressively sought opportunities for PCMH pilot development throughout the state and are pleased to report on a pilot we are developing in Fresno. We are working with the representatives of a large, self-insured employer and hope to launch a three-year pilot initially involving 50 physicians and 2,500 patients in early 2012. We obtained a grant to support the education and transformation part of this project and will continuously seek opportunities for broader implementation as the pilot progresses.

We are pursuing demonstrations and pilot opportunities made available through health care reform and seeking ways to advance the medical home model by promoting its development within ACOs.

Finally, we are sponsoring legislation to define the PCMH based on the “Joint Principles of the Patient-Centered Medical Home.”

The Colorado AFP was awarded a grant (start date July 1, 2009) to change the culture towards the PCMH in Colorado. The Chapter is collaborating with the Colorado Medical Society, The Colorado Society of Osteopathic Medicine, the Colorado Chapter of the American Academy of Pediatrics and the Colorado Clinical Guidelines Collaborative. The two-year grant will involve researching the barriers towards the PCMH among all specialties, marketing and promoting PCMH to all specialists and education. A new grant was submitted to extend and expand the current activities for an additional three years.

In addition, multiple Colorado AFP members are participating in a multi-payer, multi-state PCMH pilot. And to help members better understand how to transform their practices, the Chapter produces a monthly PCMH newsletter, CAFP Medical Home Muse.

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The Florida Chapter continues to work with Blue Cross Blue Shield of Florida in the development of a multi-pilot Primary Care Patient-Centered Medical Home demonstration project. The Chapter also presented Dr. Paul Grundy as the FAFP Foundation Guest Lecturer at its annual meeting on July 17, 2009, in Boca Raton.

In addition, the FAFP is co-hosting, along with Dr. Paul Grundy, the development of the Florida Primary Care Patient-Centered Home Collaborative. Joining the FAFP at the meeting were representatives from the Florida Chamber of Commerce and Florida-based businesses.

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The Georgia Academy of Family Physicians launched the Patient-Centered Medical Home University in November 2010. This 18-month educational program will assist small practices (of five or fewer physicians) in achieving the National Committee for Quality Assurance (NCQA) recognition as a Patient-Centered Medical Home (PCMH). There are a total of 27 practices part of this initiative that will transform their practice. Twenty-two of these practices are family medicine, one is an internal medicine practice, and three are family medicine residency programs. The outreach in Georgia of these 27 include the cities of Ocilla, Athens, Statesboro, Rome, Thomasville, Dawsonville, Conyers, Duluth, Thomason, Oakwood, Lawrenceville, East Point and Atlanta.

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The Idaho Academy of Family Physicians (IAFP) is effecting change in the primary care delivery system in Idaho by urging the involvement of business leaders, policy makers, health care providers and administrators to direct health care reform.

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In April 2011, the Illinois Academy of Family Physicians (IAFP) launched a practice transformation initiative on the Patient-Centered Medical Home (PCMH) called the Practice Improvement Network (PIN). Core components of the PIN include a robust 30-practice pilot program for small practices to implement medical home initiatives.

The pilot practices receive matching funds for their contracted relationship with an IAFP-approved coach. IAFP has recruited ambassadors from around the state with expertise in the medical home (including many who are already NCQA recognized providers) to help engage their colleagues in medical home principles.

A virtual library of educational resources and regular, dedicated communications will support the PIN initiative and engage more members across the state. An outside grant will fund additional CME programs on chronic illness care and diabetes group visits.

IAFP’s participation in Illinois Health Connect, Your Healthcare Plus and the state’s work on Health Information Exchange serves as a strong foundation to educate and support practices as they transform their clinical and practice management models towards patient centered medical homes. IAFP is committed to educating lawmakers, providers and the public about the benefits of the patient-centered medical home through the PIN initiative.

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The Indiana Academy of Family Physicians encourages its members to consider adopting the Patient-Centered Medical Home Model. The Indiana Chapter's yearly Fall Conference focuses on leadership, teamwork and Medical Home.

Currently the Indiana Chapter is involved in a three-year Medical Home Learning Collaborative with the Indiana State Department of Health, Indiana University School of Medicine and the Indiana Academy of Pediatrics. The learning collaborative is funded by a grant from the Federal Maternal and Child Health Bureau. Nine family physician practices across are involved in the Medical Home Learning Collaborative. These practices are regularly visited by a team of medical home experts who provide advice on transformation and change, have bi-weekly phone conferences to discuss change with the other practices in the learning collaborative, and attend two specialized educational conferences a year.

Although the Indiana Chapter is advocating for increased medical home payments, currently there are no increased payment rates for medical home certification in Indiana.

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The Kansas Chapter and several partners launched the Kansas Patient-Centered Medical Home Initiative in January 2011 with funding from the Kansas Health Foundation, Sunflower Foundation and the United Methodist Health Ministry Fund.
The initiative will include enhanced physician engagement, public awareness and a pilot project for eight practices. A coalition of primary care physicians groups developed the Kansas PCMH Initiative proposal. The organizations involved in the Kansas Primary Care Physician Coalition are: the Kansas Academy of Family Physicians, Kansas Association of Osteopathic Physicians, Kansas Chapter of the American Academy of Pediatrics, Kansas Chapter of the American College of Physicians and Kansas Medical Society.

The Coalition will hold the Kansas PCMH Initiative Summit 2011 in the fall of 2011, which is designed to improve health outcomes in Kansas by engaging health care providers and health care consumers in a higher level of health care dialogue.

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The Maryland Medical Home Program, established during the 2010 legislative session, is designed to improve patient health and elevate the role of family physicians and other primary care providers in our health system. The Program provides primary care physicians with financial incentives and technical assistance to implement PCMH principles into their practices.

Maryland AFP has assisted in the recruitment of approximately 50 practices for the PCMH Pilot project coordinated by the Maryland Health Care Commission. The program offers services to over 200,000 Marylanders and holds much promise for addressing some of our greatest health care challenges. By establishing a Patient-Centered Medical Home Program, we will begin to change how health care is delivered by focusing on the whole patient and improving access for the healthy and the chronically ill.

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The Michigan Academy of Family Physicians is involved in PCMH initiatives on
a state level through several large stakeholder coalitions and continues to
advocate for the PCMH model in the state legislature. The MAFP has formed a
PCMH Task Force in an effort to educate the public as well as members on the
model and help members implement elements of the PCMH into their practice
settings.

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Everything you ever wanted to know about the medical home, health care home or Patient-Centered Medical Home, with a focus on Minnesota and family medicine.

The MNAFP is monitoring activities by the Minnesota Department of Health and the Department of Human Services in the development of Health Care Home certification requirements and payment methodologies.

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The Missouri Academy of Family Physicians aligns with AAFP in support of the PCMH concept and has a board-adopted medical home definition in place. MAFP promotes the PCMH to its membership and many members have achieved PCMH recognition through the National Committee for Quality Assurance (NCQA). MAFP continues to be involved in stakeholder meetings with other health professional organizations, payers, government entities and consumers

Nebraska is in the first year of its Medicaid Patient-Centered Medical Home pilot (www.hhs.state.ne.us/med/pilot/implementation.htm), which was created by LB 396 passed in the 2009 legislative session. Two clinics in separate Nebraska communities have been chosen. One is a family medicine clinic in Lexington, Nebraska, and the other is a combined pediatric and family medicine clinic in Kearney, Nebraska.

In addition, the primary care state medical societies (family physicians, pediatricians and general internists) and the Nebraska Medical Association have all signed on to a PCMH core principals document that specifies the need to move to a payment model for care based on the joint principles document and supported by a blended payment model (combination of patient management fees, fee for service and incentive payments).

A joint committee has also been set up under the umbrella of the Nebraska Medical Association to meet with insurers to advocate for private insurance payment for the PCMH. So far, Blue Cross Blue Shield of Nebraska is starting its second phase of PCMH pilots, which will expand to about 200 providers in 2011. Other insurers have yet to step up. The committee is also looking into potential legislative options for the 2012 legislative year.

New Hampshire's Citizens Health Initiative Multi-Stakeholder Medical Home pilot and a pilot between CIGNA and Dartmouth-Hitchcock have recently ended and are compiling their outcomes.

In addition, the New Hampshire Endowment for Health is providing grant support to the Center for Medical Home Improvement to advance medical home efforts within the state.

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New York has several PCMH demonstrations underway. New York State AFP has monitored these demonstrations and one of our members is a principal in the largest PCMH demonstration, called the Adirondack PCMH demonstration.

We have participated in discussions with legislative leaders regarding policy to support the medical home model. We have also incorporated advocacy for higher reimbursement for practices that achieve medical home status into our public policy advocacy efforts. We have included PCMH presentations in our educational conferences and have published information regarding state and national developments regarding the PCMH in our newsletter and on our website.

We are in the process of meeting with health insurance plans to obtain support for a care coordination project we have developed which incorporates some elements of the PCMH, and which would align the Academy with plans in identifying interventions that could enhance the ability of a practice to function as a medical home.

The North Carolina Academy of Family Physicians has long supported the PCMH concept, particularly through support and involvement in the state’s nationally acclaimed Medicaid care management program, Community Care of North Carolina (CCNC). Presently, the NCAFP is partnering with CCNC to provide assistance to over 70 practices seeking to obtain PCMH recognition from NCQA as part of a national Medicare demonstration project taking place in eight states. Involving seven rural counties in NC, this multi-payer pilot project, if successful, will lead the way for future PCMH efforts in the state.

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The Ohio chapter continues to serve as a leading source for Patient-Centered Medical Home (PCMH) education and support in Ohio. Through its various membership services, OAFP offers the most up-to-date and current information on PCMH to its members.

Along with the other members of Ohio Coalition of Primary Care Physicians, a PCMH definition for Ohio has been developed. OAFP continues to “be at the table” with all PCMH activity throughout Ohio.

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The OAFP has formed a Medical Home Task Force with three main components: Research, Education and Advocacy.

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The Pennsylvania chapter will be offering a regional lecture series entitled “Improving Diabetes Care Using the Patient-Centered Medical Home (PCMH).”

The PAFP Foundation has many resources to help practices to become patient-centered medical homes, including CME and programs such as the Pennsylvania Improving Performance in Practice (PA IPIP), PA REACH East Program, PA IPIP Residency Collaborative, CRC Screening Collaborative and the Chronic Care Initiative.

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Glen Stream, MD, had the honor and privilege to represent the AAFP at the Rhode Island AFP meeting in Warwick, Rhode Island, June 2 - 4, 2011. Their officers are elected for two-year terms with this being an “off year” and no installations were necessary.

Rhode Island is a small but energized chapter. There was good turnout for their meeting and the group very enthusiastic. David Ashley is the current chapter president and has made PCMH the priority for his term. With his leadership, the Rhode Island has leaped ahead in PCMH implementation.

Recently, an AAFP update was provided at the opening of their CME sessions and also spoke on health care reform at the Saturday luncheon.

The CME sessions were excellent, covering a range of clinical topics. Friday afternoon was dedicated to PCMH. Rhode Island Lt. Governor Elizabeth Roberts, Paul Grundy and the RI BCBS Chief Medical Officer were all participants. Each gave an initial presentation with the group then doing a panel discussion. This is a small chapter to watch and be a role model for smaller chapter PCMH efforts.

TAFP hosts the website of a national PCMH effort. The site is a compendium of explanatory videos and interviews describing the medical home concept and its importance to patients, employers and physicians, plus a rich list of resources for use by anyone wanting to know more about the patient-centered medical home.

In addition, TAFP has created the Section on the Medical Home that meets twice a year to explore topics and develop policy relevant to this effort. The Texas Chapter continues to support and promote action at the state level and in our state agencies to expand the PCMH.

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The Washington Academy of Family Physicians (WAFP) is leading efforts to transform the delivery of primary care in Washington State. WAFP and the Washington Department of Health have partnered in a Patient-Centered Medical Home Collaborative, which is concluding its second year of a two-year collaborative.

The WAFP is the sub-awardee of the Beacon Community project of Inland Northwest, where it will provide coaching support and strategic guidance. Additionally, WAFP has partnered with the Washington State Medical Association and the Puget Sound Health Alliance to create the Clinical Performance Improvement Network (CPIN), which is an educational program designed to assist physician practices focus efforts on quality improvement.

WAFP is actively involved in supporting program communications for the Washington and Idaho Regional Extension Center (WIREC), serves on the Provider Outreach and Health IT Advisory Council, and is involved in tracking the Health Information Exchange progress in Washington State.

Through these efforts, Washington State is seeing improved patient health outcomes and improved performance in practices.

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The Wisconsin Academy of Family Physicians is pursuing a strategy of promoting public policy as well as providing education to members about the PCMH and helping them with implementation of PCMH components.

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Join a free collaborative online network committed to practice transformation. Learn more about Delta-Exchange.

This Patient-Centered Medical Home section of the AAFP web site was supported in part by a grant from Merck & Co.