1. A fundamental reason why primary care is so important may be that PCPs are more likely to engage in what is known as PCC.
This term is sometimes misunderstood; PCC does not simply mean doing whatever patients want, or providing information to them and expecting them to figure their care out on their own.
The primary care setting is probably the most advantageous for advancing PCC. However, this type of care requires a time commitment; the standard fee-for-service model generally does not reimburse PCPs for providing it.
Studies have found PCC to be associated with better care on a variety of measures, including medication adherence, disease control, quality of life, and outcomes. These were achieved without incurring higher costs.
Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Aff (Millwood). 2010;29(8):
Reference

2. The Picker PCC questionnaire, developed in 1991, is a useful starting point for understanding the concept of PCC; it has 9 domains:
Access to providers
Courtesy
Information about illness and care
Coordination of care
Attention to patient preferences
Emotional support
Family and caregiver involvement
Physical comfort
Preparation for transition to outpatient care
Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Health Serv Res. [Epub ahead of print Jul 20, 2010].
Reference

3. The slide above depicts the numerous stakeholders involved in providing PCC and the multiple touch points that will be necessary for PCMH to successfully evolve into a new model of care.
Public and private payers will play a critical role in restructuring current healthcare delivery networks and providing financial incentives to facilitate adoption and implementation of PCMH.

4. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

5. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

6. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

7. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

8. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

9. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

10. The following lists the Joint Principles of the PCMH, developed by the Patient-Centered Primary Care Collaborative and widely endorsed by prominent national organizations:
Whole-person orientation means that the personal physician is responsible for providing, or for arranging for others to provide, all of the patient’s healthcare needs at all stages of life
Care in a PCMH is coordinated and integrated across the healthcare system and the patient’s community; the necessary technological steps should be taken to ensure that patients receive care when and where they need and want it in a culturally and linguistically appropriate manner
Every patient has an ongoing relationship with a personal physician
The personal physician directs a team at the practice level who take responsibility for patients’ ongoing care
Quality and safety are key to the concept of the medical home; methods to ensure that these goals are met include:
– Having practices advocate for their patients
– Defining optimal outcomes in partnership with the patient, the patient’s family, and/or a caregiver, as appropriate
– Continuous quality improvement with patient and family participation (with the physician accountable)
– Use of information technology to improve care, track performance, educate patients, and facilitate communication
– Voluntary recognition for practices
– Use of evidence-based medicine and clinical support tools to guide decisions
Steps to enhance access include open scheduling, expanded hours, and new tools for better communication between patients and staff
Payment must be restructured to reflect work that falls outside the face-to-face visit, to support adoption of health information technology and enhanced communications, and to allow physicians to share in the savings from reduced hospitalizations
Incentives for measurable quality improvement should also be provided
Reference
Patient-Centered Primary Care Collaborative. Joint principles of the patient centered medical home Accessed September 9, 2010.

11. Assessment Question
Physicians are the center oF the healthcare system in PCMH A True B False

12. For this section of the presentation, we will be reviewing case studies in which PCMH has been implemented and examine the various successes and issues that have arisen with these pilot programs.

13. In 2006, the AAFP initiated the National Demonstration Project, a 2-year study of a PCMH.
The model chosen emphasized technological components, such as information technology and patient registries; reimbursement was not changed and connection to the larger medical neighborhood was limited.
Thirty-six diverse family practices attempted to implement the model; practices were assigned to intensive support from a facilitator or to self-direction.
Crabtree BF, Nutting PA, Miller WL, et al. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med. 2010;8(suppl 1):S80-S90.
Reference

14. Facilitation increased the proportion of components of the PCMH model that were implemented; both groups wound up with approximately 70% of the model installed, but the facilitated practices had started with fewer components in place at baseline (42% compared with 54% for the self-directed practices).1
Facilitation also increased the “adaptive reserve,” which was the investigators’ term for the relationships and leadership that allow organizational learning under the stress of change (P=0.02).2
Most practices in both groups implemented same-day appointments and same-day prescribing, and made lab results accessible to patients.1
Many practices improved management processes, adopted cost-benefit decision making, adopted improved office designs, and created a practice Web site (although few managed to create a fully functioning patient portal).1
However, e-visits, group visits, team-based care, wellness promotion, and population management proved more challenging.1
Nutting PA, Crabtree BF, Stewart EE, et al. Effect of facilitation on practice outcomes in the National Demonstration Project model of the patient-centered medical home. Ann Fam Med. 2010;8(suppl 1):S33-S44.
Nutting PA, Crabtree BF, Miller WL, et al. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010;8(suppl 1):S45-S56.
References

15. Patient outcomes were similar in facilitated and self-directed practices.
At 26 months, scores on the Ambulatory Care Quality Alliance Starter Set, which measures the quality of preventive and chronic care, improved by similar amounts in both groups.1 Chronic care scores improved significantly when taken alone, although preventive care scores did not.1
Interestingly, PCMH-specific patient ratings decreased in both groups; it is possible that either the intense effort to establish the PCMH, or some components of the PCMH themselves (such as electronic medical records in the examination room) negatively affected patient experiences.2
Jaén CR, Ferrer RL, Miller WL, et al. Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Ann Fam Med. 2010;8(Suppl 1):S57-S67.
Nutting PA, Crabtree BF, Stewart EE, et al. Effect of facilitation on practice outcomes in the National Demonstration Project model of the patient-centered medical home. Ann Fam Med. 2010;8(suppl 1):S38-S44.
References

16. Group Health Cooperative (GHC) is a nonprofit, consumer-governed, integrated health insurance and care delivery system based in Seattle.1
In GHC’s, many PCMH elements were already in place as of the early 2000s, including salary-based pay instead of fee-for-service and multidisciplinary teams led by a PCP.1
In the early 2000s, GHC implemented same-day appointments, pay adjustments for productivity, and electronic health records. The results were mixed; access and productivity improved while staff satisfaction and care quality deteriorated. The reduction in quality was reflected in an increased use of other healthcare services downstream of primary care.1
Note for Presenter: In 1997, GHC and Kaiser Permanente became affiliates. While each health plan remains independent, both collaborate on marketing to regional and national customers, sharing best practices, and offer full-service member reciprocity.2
References
1. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29:
2. Group Health Web site. Group Health Overview. Accessed December 3, 2010.