Criteria for Excellence | Appendix 3: Models of care delivery

Explore care delivery models that support high-quality family medicine training and patient care.

Use the patient-centered medical home model in residency training

The concept of the patient-centered medical home (PCMH) can be traced back to 1967 when the American Academy of Pediatrics (AAP) introduced the term “medical home” to describe the function of a single information source for children with complex medical illnesses. In 2007, the PCMH concept was codified by the American Academy of Family Physicians (AAFP), the AAP, the American College of Physicians (ACP), and the American Osteopathic Association (AOA) as the Joint Principles of the Patient-Centered Medical Home.

The Future of Family Medicine report​ provided a framework for the PCMH as a model of care that encompasses the core principles of family medicine and emerged to address the public’s long-standing perception that their medical care did not meet their needs for both comprehensive and continuous care. The principle of comprehensive care implies that family physicians will assume responsibility for the total health care of the individual and family, considering social, behavioral, economic, cultural, and biological dimensions. The principle of continuity of care implies that the family physician will provide medical services for patients throughout their lifetime in multiple settings, irrespective of gender, race, ethnic origin, or organ system involved in the disease process.

A Program of Excellence must guide residents to embrace and internalize the PCMH concept to guide the care they provide. A successful PCMH comprises the following seven elements that provide a deeper understanding of the principles of comprehensive care and continuity of services:

  1. Access to care and information, including electronic health records (EHRs), after hours and online

  2. Long-term patient-physician relationships

  3. Shared decision making

  4. Patient engagement on health and health care

  5. Interprofessional team-based care

  6. Better quality and experience of care

  7. Lower overall cost of care

The core principles defined by the PCMH are incorporated into the Merit-based Incentive Payment System (MIPS), which is a part of the Quality Payment Program (QPP) of the Medicare Access and CHIP Reauthorization Act (MACRA).

The National Committee for Quality Assurance (NCQA) and other accreditation and certification organizations developed standards by which a practice could receive certification or recognition for exemplifying the principles of the PCMH. These standards continue to evolve. The most well-known PCMH recognition comes from the NCQA, which has developed three levels of recognition.

A Program of Excellence should obtain PCMH recognition by the NCQA or a similar organization as a step in creating a high-quality clinical environment for family medicine residency education. However, this alone is insufficient to ensure a culture of quality health and health care. There is growing realization in the quality and educational communities that recognition alone does not equal quality; rather, it is a marker that a practice has processes and systems in place that could lead to improved quality of care.

While people have different expectations regarding what a PCMH should accomplish, the general model has become the backbone of multiple physician and commercial practices. Evidence of the effectiveness of the PCMH model remains mixed. Improvement in quality indicators seems consistent, but the effect on cost and patient satisfaction is less clear. The PCMH model continues to be refined, and the evidence base for PCMH practice continues to grow.

Transform the residency practice with a Clinic First model

Apply the building blocks of high-performing residency clinics

The 10+3 Building Blocks model includes ten building blocks of high-performing primary care practices, as well as three additional blocks that are specific to residency programs with a Clinic First orientation (Figure 1A).

Figure 1A. The 10+3 Building Blocks Model for residency teaching clinics

The 10+3 Building Blocks Model for residency teaching clinics

Shared with permission from Bodenheimer T, Gupta R, Dubé K, et al. High-functioning primary care residency clinics​. Building blocks for providing excellent care and training. Association of American Medical Colleges;
2016.

Table 2A highlights some of these fundamental building blocks for providing excellent care and training that are likely to resonate with most program leaders as they reflect on their own program improvement efforts.

Table 2A. Selected building blocks of high-performing primary care

Building Block 1: Engaged leadership Clinic and residency leaders work closely together and prioritize missions of both patient care and
education—“the clinic is the curriculum.”
Building Block 2: Data-driven improvement Performance data on a range of clinical, operational, cost, patient, resident, and staff experience are
available and transparent across clinic, team, and clinician (including resident) levels. Measures are
made meaningful and actionable for residents and teams. Resident schedules prioritize participation.
Building Block 3: Empanelment Each patient chooses or is assigned to a faculty member or resident. Clear processes exist for reassigning panels when residents graduate.
Building Block 4: Team-based care Clinicians and staff, including residents, always work on their team and are not shuttled back and forth from one team to another. These stable teams allow team members (faculty, midlevel providers, and nursing personnel) to provide continuity when residents are not in clinic. Co-location and huddles enhance a cohesive team culture and facilitate
communication among team members. Small teams, or large teams subdivided into teamlets, allow patients to know their team members and team members to know their patients.
Resident Building Block 1: Resident scheduling* Resident schedules balance the priority of clinic and inpatient settings. Residents are scheduled in clinic regularly, predictably, and far in advance, with short intervals between clinic times, in order to maintain stable teams and provide patient continuity. Block scheduling eliminates the tension between
simultaneous inpatient and outpatient duties. A small core of faculty physicians—dedicated to ambulatory primary care and resident teaching—are in clinic the
majority of the time to lead clinic improvement.
Resident Building Block 2:
Resident engagement		 Residents learn about practice transformation through engagement in, and leadership of,
sustainable clinic-improvement projects based on clinic priorities.
Resident Building Block 3:
Resident worklife		 Resident experience and burnout are assessed, and structures exist for actively responding to resident
feedback. Well-functioning clinics create positive clinic experiences for residents and, thus, positive attitudes toward primary care careers.

Lead practice transformation and innovation

Residency Program Solutions (RPS) is interested in the many radical redesigns throughout the country that involve significant changes in resident schedules, such as the 2+2 programs in which residents spend time solely in the hospital and clinic, avoiding split time. Some have required waivers from the American Board of Family Medicine (ABFM) continuity requirements for eligibility for the initial certification examination. RPS recognizes that each program is unique in its culture and situation and believes that practice transformation and innovation endorsing the fundamental Clinic First building blocks will likely take many forms. The details of each program’s improvement efforts will vary in part because of its unique sponsor and condition. For example, military-sponsored programs, academic programs, community hospital-sponsored programs, teaching health centers, and large health care systems will all lead change differently.

RPS wants to highlight the fact that transformation is a journey. It takes years of skillful, adaptive leadership that respects the challenges of changing culture, traditions, and the very DNA of any program. Programs of Excellence will proceed cautiously when addressing the challenges of leading transformational change. Using the Criteria for Excellence self-assessment tools and resources will help programs be better prepared to succeed over time.

Explore advanced primary care delivery models

Shortly after the original Joint Principles of the Patient-Centered Medical Home were released in 2007, many recognized that it would be extremely difficult to achieve the aims of the PCMH without attending to the behavioral health needs of patients through an integrated approach. Key stakeholders in the primary care and behavioral health communities developed Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home in 2014.

Through the Patient-Centered Primary Care Collaborative (PCPCC), a diverse group of stakeholders that included physicians, consumers, employers, health plans, behavioral and oral clinicians, and others collaborated to develop the Shared Principles of Primary Care. This further expanded upon the Joint Principles of the Patient-Centered Medical Home to add emphasis on team- based care, stewardship of resources, and health equity.

The Centers for Medicare & Medicaid Services (CMS) is attempting to move beyond the PCMH model and accelerate to more advanced models of primary care to improve care and control or reduce health care costs. The Center for Medicare & Medicaid Innovation (CMMI) was created as part of the Patient Protection and Affordable Care Act (ACA), which was signed into law in 2010.

The CMMI was tasked with developing and funding demonstration projects to improve the quality of care for patients.

The CMMI launched the Comprehensive Primary Care Initiative (CPCI) in 2012 and a follow-up expansion called Comprehensive Primary Care Plus (CPC+) in 2017. CPC+ involved more than 3,000 practices nationwide, including 500 residency practices. It concluded in 2021, and interim findings are available on the CMS Innovation Center website.

CPC+ was a national advanced primary care medical home model designed to improve primary care quality, access, and efficiency by transforming care delivery across the following five comprehensive primary care functions:

  1. Access and continuity: The goal is to recognize that the needs of patients are not limited to the hours that the practice may be open for care. Tools such as secure email and a web portal allow patients to access their medical information when they need it.
  2. Care management: The goal is to help patients achieve optimal health by preventing disease, stabilizing current chronic conditions, and preventing acceleration to higher-risk categories. The practice can assign a health risk status to each patient and direct its resources accordingly. The AAFP and others have illustrative tools that can become the basis for care management at the practice level.
  3. Comprehensiveness and coordination: The goal is to work closely with other health care professionals to exchange information and to coordinate and manage referrals and care transitions.
  4. Patient and caregiver engagement: The goal is to engage patients and caregivers in a process of shared decision making in all aspects of care, utilizing decision aids.
  5. Planned care and population health: The goal is for practices to proactively assess patients to determine their needs and provide appropriate and timely chronic and preventive care, including medication management and review. Team-based care is personalized to the needs of the patient. This includes integration of behavioral health to address motivation and behavioral issues that can impact overall health. It also includes medication management and review by a clinical pharmacist.

The most interesting interim finding of the CPCI and CPC+ model review was the lack of clear benefit for the comprehensive primary care approach. Specifically, compared to matched non-participating practices, CPC+ practices did not improve quality metrics, patient satisfaction, or physician and staff satisfaction more than the control practices. (There were improvements in all domains over the period, but CPC+ practices did not outperform the PCMH-certified controls). There were cost savings in emergency department (ED) and hospital utilization, but these were offset by the additional primary care resources devoted to the CPC+ practices, so there was no significant net economic benefit.

Evaluation of the CPC+ model pointed to the following important staffing implications of advanced practice models:

  • Staffing must be considered in terms of functions and team organization. For example, all advanced practice models require robust information technology (IT) with multiple population-based registries and effective health information exchange capabilities. Currently, no EHR has out-of-the-box functionality to meet advanced practice IT needs, so some dedicated internal IT resources are required. In larger groups, this expertise often can be shared across several practices, but smaller groups and single practices often have difficulty finding and retaining appropriate staff and have much higher costs per full-time equivalent (FTE) for adequate IT support.

  • Solid data on the number of FTEs or FTE/severity-adjusted panel size are not yet well calibrated and there are no clear benchmarks. Support for these models requires either capitation at a reasonable per member per month (PMPM) rate or a significant care management fee in addition to fee-for-service (FFS) revenue or some form of cost-based or bundled reimbursement. These innovations are not sustainable in a strictly FFS environment.

  • Database manipulation and patient outreach for chronic illness and patient outreach for preventive services are most effectively done by team members other than the physician. This requires some dedicated non- physician time, frequently by medical assistants (MAs), physician assistants (PAs), or nurse practitioners (NPs).

  • PAs/NPs are valuable team members, especially if they can provide expanded access and deal with same-day appointments. They also can handle much of the patient portal activity and effectively deal with triage questions that are beyond the capacity of MAs.

In 2019, CMMI announced new alternative payment models for primary care physicians. The CMS Primary Cares Initiative provides five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC). Both were intended to be Advanced Alternative Payment Models (AAPMs) tested for five years. PCF was launched in January of 2021, and the second wave began in January 2022.

The PCF models are designed to be transparent and simple and to create opportunities for practices ready to take on more risk through payments based on utilization outcomes. PCF practices are required to provide the five key functions of a medical home. However, CMS is not prescriptive regarding the interventions a practice uses to meet these functions.

The DC models are built on the Next Generation Accountable Care Organization (ACO) model and offer new forms of population-based payment, enhanced cash flow options, and an increased flexibility that allows practices to meet beneficiaries’ medical and social needs. These models aim to reduce costs and improve the quality of care for beneficiaries in Medicare FFS.

The Direct Primary Care (DPC) model gives family physicians a meaningful alternative to FFS insurance billing, typically by charging patients a monthly, quarterly, or annual fee (i.e., a retainer) that covers all or most primary care services, including clinical, laboratory, and consultative services, as well as care coordination and comprehensive care management.

Various DPC models exist, and practices that utilize this alternative payment model do not necessarily practice advanced care delivery. There is a need for exposure to DPC during training, but it has not served as the base practice model for major family medicine training programs.

Apply lessons from evolving primary care models

A Program of Excellence will keep current with the range of primary care demonstration projects (e.g., CPC+, the PCF models) and incorporate outcomes of these projects as they become available. Residency programs should also consider how some efforts that support the five comprehensive primary care functions can be implemented within the current payment system (e.g., risk stratification, patient and family advisory councils), even without targeted funding. For example, in many settings, behavioral health integration can be budget neutral because the practice can bill for mental health services. Also, efforts at reducing ED and hospital utilization are facilitated by properly billing transitional care management and chronic care management CPT codes.

Medicare Access and CHIP Reauthorization Act and the Quality Payment Program

QPP is rapidly evolving, particularly with some of the reporting and rule changes resulting from the COVID-19 pandemic, and information will need to be updated regularly. To earn positive MIPS payment adjustments and avoid negative adjustments, eligible clinicians (ECs) must submit performance data in three categories:

  1. Quality: Report at least six measures, one of which must be an outcome measure

  2. Promoting interoperability: Report on required measures regarding certified electronic health record technology (CEHRT) capabilities

  3. Improvement activities: Report two high-weighted activities, four medium-weighted activities, or a combination of both; full credit is automatic for certified or recognized PCMHs.

Family medicine practices can submit data as individuals or as a group. Eligible clinicians excluded from MIPS include:

  • ECs who are below the volume threshold

  • ECs in their first year of participation in Medicare

  • Qualifying and partial qualifying AAPM participants who qualify for the AAPM bonus

Residents may be MIPS-eligible if they moonlight in their second or third year of residency. Residents who moonlight in the third year become eligible for MIPS in their first year of practice.

Educational materials available for free to AAFP members and on the CMS Quality Payment Program website provide information regarding data submission and options and can be of use in developing curricula.

Some residency practices can avoid MIPS and participate in qualifying AAPM models available in their area. However, even if the practice is not participating in a qualifying AAPM, it is important for all eligible faculty to participate in the QPP and for residents to get regular feedback on nationally benchmarked quality performance metrics.

  1. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine summary and impact of major requirement revisions. 2021. Accessed November 20, 2022.
  2. Neutze D, Hodge B, Steinbacher E, et al. The practice is the curriculum. Fam Med. 2021;53(7):567-574.
  3. Bazemore A, Petterson S, Peterson LE, et al. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16(6):492-497.
  4. Bodenheimer T, Gupta R, Dubé K, et al. High-functioning primary care residency clinics. Building blocks for providing excellent care and training. Association of American Medical Colleges; 2016. Accessed November 20, 2022.
  5. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine. September 17, 2022. Accessed January 31, 2023.
  6. Patel MS, Arron MJ, Sinsky TA, et al. Estimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care. 2013;19(6):509-516.
  7. Berkowitz SA, Parashuram S, Rowan K, et al. Association of a care coordination model with health care costs and utilization: The Johns Hopkins Community Health Partnership (J-CHiP). JAMA Netw Open. 2018;1(7):e184273.
  8. Jones L, Wells K. Strategies for academic and clinician engagement in community-participatory partnered research. JAMA. 2007;297(4):407-410.
  9. Hughes LS, Tuggy M, Pugno PA, et al. Transforming training to build the family physician workforce our country needs. Fam Med. 2015;47(8):620-627.
  10. Jacobs C, Seehaver A, Skiold-Hanlin S. A longitudinal underserved community curriculum for family medicine residents. Fam Med. 2019;51(1):48-54.
  11. Gotler RS, Green LA, Etz RS. What 1966 can teach us about the future of primary care: the case for communities of solution. Milbank Q Opinion. Published June 10, 2020. Accessed October 26, 2022.
  12. Gard LA, Peterson J, Miller C, et al. Social determinants of health training in U.S. primary care residency programs: a scoping review. Acad Med. 2019;94(1):135-143.
  13. Chang CH, Stukel TA, Flood AB, et al. Primary care physician workforce and Medicare beneficiaries' health outcomes [published correction appears in JAMA. 2011;306(2):162]. JAMA. 2011;305(20):2096-2104.
  14. Bar-Dayan Y, Saed H, Boaz M, et al. Using electronic health records to save money. J Am Med Inform Assoc. 2013;20(e1):e17-e20.
  15. Ornstein SM, Nietert PJ, Jenkins RG, et al. The prevalence of chronic diseases and multimorbidity in primary care practice: a PPRNet report. J Am Board Fam Med. 2013;26(5):518-524.
  16. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2:445-451.
  17. Caines LC, Brockmeyer DM, Tess AV, et al. The revolving door of resident continuity practice: identifying gaps in transitions of care. J Gen Intern Med. 2011;26(9):995-998.
  18. O’Gurek DT, Henke C. A practical approach to screening for social determinants of health. Fam Pract Manag. 2018;25(3):7-12.
  19. Kwan BM, Valeras AB, Levey SB, et al. An evidence roadmap for implementation of integrated behavioral health under the Affordable Care Act. AIMS Public Health. 2015;2(4):691-717.