1. Kagman Community Health Center
Introduction to the Patient-Centered Medical Home Vincent Castro, Executive Director Katherine Elstun, MD, Medical Director
PCPCC Map Tools. (2015). Patient-Centered Medical Home 101: General Overview. Patient-Centered Primary Care Collaborative. Accessed at

2. Defining the Medical Home
The medical home is an approach to primary care
Committed to Quality and Safety
Maximizes use of health IT, decision support and other tools
Accessible
Care is delivered with short waiting times, 24/7 access and extended in-person hours
Coordinated
Care is organized across the ‘medical neighborhood’
Comprehensive
Whole-person care provided by a team
Person-Centered
Supports patients and families in managing decisions and care plans
Source:

3. UCSF Center for Excellence in Primary Care. http://www. ucsf
 Source: UCSF Center for Excellence in Primary Care.

4. PCMH at  of “Medical Neighborhood”
Hospital
Home
Health
Health IT $
Patient-Centered Medical Home
Public Health
Employers
Schools
Faith-Based Organizations
Community Centers
Diagnostics
Pharmacy
Mental
Health
Specialty & Subspecialty
Skilled Nursing Facility $
Health IT
Health Care Delivery Organizations
Community Organizations

5. Utilize care teams Care coordinators Health coaches Peer support
Care managers
Community supports and social workers
Pharmacists
Patients, families & Caregivers

6. Include patients, families & caregivers as part of care team
Consider experience of care from the patient’s perspective – and include families & caregivers
Patients with multiple chronic conditions (and/or their caregivers) often in best position to advise care team on challenges/opportunities to improve care
Through their stories, patients can energize and encourage team to promote compassionate care

7. KCHC Patient Engagement Contract
Dear Patient,
Welcome and thank you for choosing KCHC. We are committed to providing you with the best medical care based on your health needs. Our hope is that we can form a partnership to keep your whole self as healthy as possible, no matter what your current state of health.
Your commitment to our patient-centered medical home practice will provide you with an expanded type of care. We will work with both you and other health care providers as a team to take care of you. You will also have better access to us through phone and group visits.
As your primary care team, we will:
Learn about you, your family, life situation, and health goals and preferences. We will remember these and your health history every time you seek care and suggest treatments that make sense for you.
Take care of any short-term illness, long-term chronic disease, and your all-around well-being.
Keep you up-to-date on all your vaccines and preventive screenings.
Connect you with other members of your care team (specialists, health coaches, etc.) and coordinate your care with them as your health needs change.
Be available to you after hours for your urgent needs.
Notify you of test results in a timely manner.
Communicate clearly with you so you understand your condition(s) and all your options.
Listen to your questions and feelings. We will respond promptly to you – and your calls – in a way you understand.
Help you make the best decisions for your care.
Give you information about classes, support groups, or other services that can help you learn more about your condition and stay healthy.

8. KCHC Patient Engagement Contract
We trust you, as our patient, to:
Know that you are a full partner with us in your care.
Come to each visit with any updates on medications, dietary supplements, or remedies you’re using, and questions you may have.
Let us know when you see other health care providers so we can help coordinate the best care for you.
Keep scheduled appointments or call to reschedule or cancel as early as possible.
Understand your health condition: ask questions about your care and tell us when you don’t understand something.
Learn about your condition(s) and what you can do to stay as healthy as possible.
Follow the plan that we have agreed is best for your health.
Take medications as prescribed.
Call if you do not receive your test results within two weeks.
Contact us after hours only if your issue cannot wait until the next work day.
If possible, contact us before going to the emergency room so someone who knows your medical history can care for you.
Agree that all health care providers in my care team will receive all information related to your health care.
Pay your share of any fees.
Give us feedback to help us improve our care for you.
I look forward to working with you as your primary care provider in your patient-centered medical home.
Provider Signature Printed Provider Name Date
__________________________ __________________________________ __________________
Patient Signature Printed Patient Name Date

9. Kagman Community Health Center - PCMH
Benefits of the PCMH
Cost Savings
Fewer ER visits/Hospitalizations
Improved Health
Improved patient and staff satisfaction

10. Reported Outcomes: Cost Savings
Program
Outcomes
Date Published
Report Type
Anthem BC ACO
$4.7 Million (in 6 months)
June 2014
Industry Report
BCBS Michigan PCMH Program
$26.37 PMPM ( )
$155 million ( )
July 2013
Peer-Reviewed
Oregon Coordinated Care Organizations (Medicaid)
18-19% reduction in ER visit spending
Nov 2013,
Vermont Blueprint for Health (Multi-Payer)
Reduced expenditures in 2012 by:
$386 PMPY commercial (ages 1-17)
$586 PMPY commercial (ages )
$200 PMPY Medicaid (ages 1-17)
$447 PMPY Medicaid (ages 18-64)
Jan 2014
CareFirst BCBS PCMH Program (DC, MD, VA)
$267 million avoided costs ( )
July 2014
Monarch Healthcare CMS Pioneer ACO (CA)
5.4% reduction in medical costs in 2012 (Medicare)
Horizon BCBS of New Jersey PCMH Program
$4.5 million savings (ER visits and hospitalizations)
4% lower total cost of care (all patients)
4% lower cost of care (diabetes patients)
Independence BC PCMH Program (PA)
Total cost savings for high risk groups:
7.9% and 11.2% (2010, 2009)
March 2014

11. Reported Outcomes: Cost Savings
Program
Outcomes
Date Published
Report Type
Anthem BC ACO
$4.7 Million (in 6 months)
June 2014
Industry Report
BCBS Michigan PCMH Program
$26.37 PMPM ( )
$155 million ( )
July 2013
Peer-Reviewed
Oregon Coordinated Care Organizations (Medicaid)
18-19% reduction in ER visit spending
Nov 2013,
Vermont Blueprint for Health (Multi-Payer)
Reduced expenditures in 2012 by:
$386 PMPY commercial (ages 1-17)
$586 PMPY commercial (ages )
$200 PMPY Medicaid (ages 1-17)
$447 PMPY Medicaid (ages 18-64)
Jan 2014
CareFirst BCBS PCMH Program (DC, MD, VA)
$267 million avoided costs ( )
July 2014
Monarch Healthcare CMS Pioneer ACO (CA)
5.4% reduction in medical costs in 2012 (Medicare)
Horizon BCBS of New Jersey PCMH Program
$4.5 million savings (ER visits and hospitalizations)
4% lower total cost of care (all patients)
4% lower cost of care (diabetes patients)
Independence BC PCMH Program (PA)
Total cost savings for high risk groups:
7.9% and 11.2% (2010, 2009)
March 2014

12. Reported Outcomes: Fewer ER/Hospital Visits
Program
Outcomes
Date Published
Report Type
Aetna PCMH - New York
35% fewer hospital admissions (WESTMED Medical Group, year 1)
June 2014
Industry Report
CareFirst BCBS PCMH Program (DC, MD, VA)
6.4% fewer hospital admissions
8.1% fewer readmissions (all-cause)
11.1% fewer hospital days
July 2014
BCBS Michigan PCMH Program
27.5% lower hospital stays
11.8% lower PC-sensitive ER visits (adults)
9.9% lower ER visits (adults)
14.9% lower ER visits (pediatrics)
Missouri Health Homes (Medicaid)
6-8% decrease in ER use
10-13% decrease in hospitalizations
Nov 2013
New York Health Homes (Medicaid)
23% decrease in hospital admissions and ER visits
March 2014
Rhode Island Chronic Care Sustainability Initiative (Multi-Payer)
11.6% fewer ambulatory-sensitive ER visits (2013)
Fewer inpatient hospitalizations among more experienced participants (2014)
Nov 2013,
May 2014
Peer-Reviewed,
PCPCC’s compiled source of programs (Filter results by “Fewer ED / Hospital Visits”):
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed January
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September

13. Reported Outcomes: Fewer ER/Hospital Visits
Program
Outcomes
Date Published
Report Type
Aetna PCMH - New York
35% fewer hospital admissions (WESTMED Medical Group, year 1)
June 2014
Industry Report
CareFirst BCBS PCMH Program (DC, MD, VA)
6.4% fewer hospital admissions
8.1% fewer readmissions (all-cause)
11.1% fewer hospital days
July 2014
BCBS Michigan PCMH Program
27.5% lower hospital stays
11.8% lower PC-sensitive ER visits (adults)
9.9% lower ER visits (adults)
14.9% lower ER visits (pediatrics)
Missouri Health Homes (Medicaid)
6-8% decrease in ER use
10-13% decrease in hospitalizations
Nov 2013
New York Health Homes (Medicaid)
23% decrease in hospital admissions and ER visits
March 2014
Rhode Island Chronic Care Sustainability Initiative (Multi-Payer)
11.6% fewer ambulatory-sensitive ER visits (2013)
Fewer inpatient hospitalizations among more experienced participants (2014)
Nov 2013,
May 2014
Peer-Reviewed,
PCPCC’s compiled source of programs (Filter results by “Fewer ED / Hospital Visits”):
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed January
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September

14. Reported Outcomes: Improved Health
Program
Outcomes
Date Published
Report Type
Anthem BC ACO (CA)
Increase in meeting quality measures:
7.5% LDL (diabetes)
3.8% in cholesterol management for heart disease patients
June 2014
Industry Report
CareFirst PCMH Program (DC, MD, VA)
3.7% higher quality scores for panels receiving incentives
9.3% higher quality scores for PCMH panels ( )
June 2013
Horizon BCBS NJ PCMH Program
14% higher rate in improved diabetes control
12% higher rate in cholesterol management
July 2014
South Central Pennsylvania Alliance
Improved blood pressure control from 67% in 2010 to 79% in 2013 (East Berlin Family Medicine practice)
Fresno PCMH Initiative (CA-AFP)
50% increase in diabetes patients with controlled blood sugar after 1-yr pilot
Feb 2014
Primary Care Information Project (NY Medicaid)
Outperformed non-PCMH practices on BP control in hypertension/ diabetes patients, and smoking cessation intervention measures
Peer-Reviewed
PCPCC’s compiled source of programs (Filter results by “Improved Health”):
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed January
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September

15. Reported Outcomes: Improved Health
Program
Outcomes
Date Published
Report Type
Anthem BC ACO (CA)
Increase in meeting quality measures:
7.5% LDL (diabetes)
3.8% in cholesterol management for heart disease patients
June 2014
Industry Report
CareFirst PCMH Program (DC, MD, VA)
3.7% higher quality scores for panels receiving incentives
9.3% higher quality scores for PCMH panels ( )
June 2013
Horizon BCBS NJ PCMH Program
14% higher rate in improved diabetes control
12% higher rate in cholesterol management
July 2014
South Central Pennsylvania Alliance
Improved blood pressure control from 67% in 2010 to 79% in 2013 (East Berlin Family Medicine practice)
Fresno PCMH Initiative (CA-AFP)
50% increase in diabetes patients with controlled blood sugar after 1-yr pilot
Feb 2014
Primary Care Information Project (NY Medicaid)
Outperformed non-PCMH practices on BP control in hypertension/ diabetes patients, and smoking cessation intervention measures
Peer-Reviewed
PCPCC’s compiled source of programs (Filter results by “Improved Health”):
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed January
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September

16. Reported Outcomes: Improved Patient/Clinician Satisfaction
Program
Outcomes
Date Published
Report Type
Fresno PCMH Initiative (CA-AFP)
Overall improvement in patient satisfaction
Feb 2014
Industry Report
MGM Resorts Direct Care Health Plan
88% satisfaction rating among members (2013)
Jan 2014
Rhode Island Chronic Care Sustainability Initiative (Multi-Payer)
Practices increased their positive patient experience ratings for:
access to care
communication with care team
office staff responsiveness
shared decision-making
self-management support
May 2014
VA Patient-Aligned Care Team (National)
Lower staff burnout in PCMH practices (2.29 vs. 2.80, p=.02)
Higher patient satisfaction scores in PCMH practices (9.33 vs. 7.53, p<.001)
June 2014
Peer-Reviewed
PCPCC’s compiled source of programs (Filter results by “Improved Patient/Clinician Satisfaction”):
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed January
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September

17. Reported Outcomes: Improved Patient/Clinician Satisfaction
Program
Outcomes
Date Published
Report Type
Fresno PCMH Initiative (CA-AFP)
Overall improvement in patient satisfaction
Feb 2014
Industry Report
MGM Resorts Direct Care Health Plan
88% satisfaction rating among members (2013)
Jan 2014
Rhode Island Chronic Care Sustainability Initiative (Multi-Payer)
Practices increased their positive patient experience ratings for:
access to care
communication with care team
office staff responsiveness
shared decision-making
self-management support
May 2014
VA Patient-Aligned Care Team (National)
Lower staff burnout in PCMH practices (2.29 vs. 2.80, p=.02)
Higher patient satisfaction scores in PCMH practices (9.33 vs. 7.53, p<.001)
June 2014
Peer-Reviewed
PCPCC’s compiled source of programs (Filter results by “Improved Patient/Clinician Satisfaction”):
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed January
Source: Primary Care Innovations and PCMH Map by Outcomes. PCPCC. Accessed September

18. Kagman Community Health Center

19. Thank You Kagman Community Health Center
PCPCC Map Tools. (2015). Patient-Centered Medical Home 101: General Overview. Patient-Centered Primary Care Collaborative. Accessed at