Year
Version
Elements of the program
2003
Physician Practice Connections (PPC)
This PCMH precursor recognized use of systematic processes and health IT to:
Know and use patient history
Follow up with patients and other providers
Manage patient populations and use evidence-based care
Employ electronic tools to prevent medical errors
2008
Physician Practice Connections – Patient-Centered Medical Home (PPC-PCMH)
The first PCMH model implemented the joint principles, emphasizing:
Ongoing relationship with personal physician
Team-based care
Whole-person orientation
Care coordination and integration
Focus on quality, safety, and enhanced access
2011
PCMH 2011
Explicitly incorporated health information technology meaningful use criteria
Added content and examples for pediatric practices on parental decision making, age-appropriate immunizations, teen privacy, and other issues
Added voluntary distinction for practices that participate in the CAHPS PCMH survey of patient experience and submit data to NCQA
Added content and examples for behavioral health care
2014
PCMH 2014
More integration of behavioral health care
Additional emphasis on team-based care
Focus care management for high-need populations
Encourage involvement of patients and families in QI activities
Alignment of QI activities with the triple aim: improved quality, cost, and experience of care
Alignment with health information technology meaningful use stage 2
The PCMH model has been endorsed by multiple medical societies, including the American Medical Association, the American College of Cardiology, the American Society of Clinical Oncology, the American Academy of Neurology, the Society of Critical Care Medicine, as well as the aforementioned four primary care groups. It is strongly promoted by the PCPCC representing employers, consumer groups, and professional societies as well as being a part of CMS national demonstration projects.
The Medical Neighborhood
With the success of the PCMH programs, the non-primary care medical specialties advocated for their role in a PCMH for the appropriateness of specialist-delivered primary care. This was thought by some to be a reaction by those specialties to health-care reform dollars being channeled to the primary care sector at the expense of specialty services, as they were at the start of the health maintenance organizations (HMOs) (Diamond 2010).
The Council of Subspecialty Societies (CSS) of the ACP established a workgroup in 2007 to specifically address the perceived relationship between the PCMH care model and specialty/subspecialty practices (Kirschner and Barr 2010). They concluded that the PCMH model provides no incentive to limit appropriate referrals to specialists or subspecialists by a patient’s personal physician and does not prohibit patients from choosing to see a specialist or subspecialist of their choice. Furthermore, although the PCMH is most compatible with primary care practices, it did emphasize that specialists can participate as long as they provide primary care services, including first-contact and comprehensive care, as well as meet the recognition process requirements of a PCMH. In addition, the PCMH model would appear to be appropriate for the subset of patients in specialty or subspecialty practices who are receiving long-term, principal care for a condition by physicians in that practice, such as a pulmonologist caring for patients with chronic lung conditions or and endocrinology practice caring for complex diabetics.
A later study did corroborate that applying PCMH principles to a specialty clinic improved outcomes: at VA-run HIV clinics, more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient’s medical home and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care (Fix et al. 2014).
Fisher (2008) coined the term medical neighborhood to describe the barriers for PCMHs to reach their full potential. In his article, he states that the medical home has great potential to improve the provision of primary care and the financial stability of primary care practice. Missing so far in the PCMH has been an effort to implement this model in concert with other reforms that more effectively align the interests of all physicians and hospitals toward the improvement of patient care. To deliver on its promise, the medical home needs a hospitable and high-performing medical neighborhood.
Fisher described several approaches to overcome barriers which then would strengthen medical home models:
Resistance to collaboration because there are few incentives for hospitals and specialists to collaborate with primary care physicians would be balanced by requiring medical homes to specify practice networks for performance measurement and information sharing.
Institute transparent performance measurements across the continuum of care and reward collaboration through pay for performance or shared savings.
Foster integrated delivery systems that share savings from improved quality of care and lower costs for patients.
Within a short time, an important position paper outlining criteria to become a PCMH Neighbor (PCMH-N) by the ACP (2010) solidified primary care as the stewards of PCMHs and more realistically clarified the relationship of the non-primary medical specialties to the PCMH with the following points:
- 1.
The ACP recognizes the importance of collaboration with specialty and subspecialty practices to achieve the goal of improved care integration and coordination within PCMH care delivery model.
- 2.
The ACP approves the following definition of a PCMH-N as it pertains to specialty and subspecialty practices:
A specialty/subspecialty practice recognized as a PCMH-N engages in processes that:
Ensure effective communication, coordination, and integration with PCMH practices in a bidirectional manner to provide high-quality and efficient care.
Ensure appropriate and timely consultations and referrals that complement the aims of the PCMH practice.
Ensure the efficient, appropriate, and effective flow of necessary patient and care information.
Effectively guide determination of responsibility in co-management situations.
Support patient-centered care, enhanced care access, and high levels of care quality and safety.
Support the PCMH practice as the provider of whole-person primary care to the patient and as having overall responsibility for ensuring the coordination and integration of the care provided by all involved physicians and other health-care professionals.
- 3.
The ACP approves the following framework to categorize interactions between PCMH and PCMH-N practices:
The clinical interactions between the PCMH and the PCMH-N can take the following forms:
Preconsultation exchange – intended to expedite/prioritize care or clarify need for a referral
Formal consultation – to deal with a discrete question/procedure
Co-management
Co-management with shared management for the disease
Co-management with principal care for the disease
Co-management with principal care of the patient for a consuming illness for a limited period
Transfer of patient to specialty PCMH for the entirety of care
- 4.
The position paper went on to recommend the aspirational guiding principles for the development of care coordination agreements between PCMH and PCMH-N practices to further define the relationship.
Subsequent to the ACP position paper, an AHRQ panel created its own white paper on the PCMH-N (Taylor et al. 2011). This equally important document broadened the view from just the primary care specialist or physician-hospital interactions to incorporate community and social services and a more expansive policy perspective. The AHRQ authors defined the medical neighborhood as a PCMH and the many other clinicians providing health-care services to patients within it, along with community and social service organizations and state and local public health agencies. In this way, they surmised, the PCMH and the surrounding medical neighborhood would focus on meeting the needs of the individual patient but also incorporate aspects of population health and overall community health needs in its objectives.
The PCMH was designated as the center of the medical neighborhood, given its role as the central point of contact for the patient and primary coordinator of the patient’s care across various neighbors. Within the PCMH, the primary clinician caring for the patient may be a physician, nurse practitioner, or physician assistant. Importantly, the neighborhood is not necessarily a geographic construct but instead a set of relationships revolving around the patient and his or her PCMH, based on that patient’s health-care needs.
For some patients, the authors write, the medical neighborhood may be centered on specific specialists rather than primary care; this might include patients with severe and persistent mental illness, those living with AIDS, and those with a new diagnosis of cancer. In such cases, as noted previously, the role of the specialist and the primary care clinician might be reversed, but the specialist must insure that patients have access to a full range of primary care services, and the primary care team might serve as consultants.
In addition, the AHRQ authors stated that a well-functioning medical neighborhood would include the following:
Clear agreement on and delineation of the respective roles of neighbors in the system (e.g., through care coordination agreements between PCCs and specialty physicians, agreements on care transitions, pre-referral arrangements, referral and follow-up guidelines from professional societies, or others)
Sharing of the clinical information needed for effective decision making and reducing duplication and waste in the system, supported by appropriate health IT systems
Care teams, typically anchored by the PCMH, to develop individualized care plans for complex patients (such as those with multiple chronic conditions) that describe a proactive sequence of health-care interventions and interactions – followed by tracking and assisting to ensure that this takes place (including care transitions)
Continuity of needed medical care when patients transition between settings (e.g., when transferred from a hospital to a skilled nursing facility and then to an assisted living facility), with active communication, coordination, and collaboration among everyone involved in the patient’s care, including clinicians, patient, and familyRelated posts:
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