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PCMH Work Group Summaries

Summary reports from the six PCMH Workgroups are below.  Click on the link in the following list to find the summary you wish to view:

Payment Reform 

Bruce Landon, Samuel Edwards, Gary Rosenthal, Eugene Rich, Robert Berenson, Meredith Rosenthal, and Melinda Abrams

It is widely recognized that transforming primary care practice around the patient centered medical home (PCMH) model will require fundamental changes to physician payment. These changes must move beyond current fee-for-service (FFS) models, which incentivize frequent, short, low-value encounters and which do not reimburse the care coordination activities that are integral to the success of the PCMH model. 

Prior discussions surrounding payment reform have centered on a number of discrete models for supporting the PCMH, including modified FFS models and fully capitated models that reimburse practices using a fixed risk-adjusted payment covering all primary care services.  

Recent changes in the practice environment that have arisen since the passage of the Patient Protection and Affordable Care Act (ACA) hold significant implications for the organization and payment of primary care, through expansion of those insured who will seek health care in already overstretched primary care system, the impact of increased FFS payments and the reorganization efforts to the healthcare delivery system through, for example, Accountable Care Organizations (ACOs).  PCMHs should be a foundational element for ACOs and while some ACO demonstrations evolved from PCMH projects, the emergence of ACOs and larger integrated delivery models raise important new issues regarding PCMH payment reform (cost savings efforts, how varying ACO structures impact revenue and the metrics of physician performance that affect payment and capture such dimensions as non-visit based care coordination and effective teamwork).

Key research questions that emerge from these new and emerging issues include:
  • How will the PCMH model differ inside ACOs versus outside of ACOs?
  • What are optimal ways for ACOs to invest in PCMH transformation? How will such investments vary according to the organization of the ACO?
  • What is the role of insurers in specifying PCMH incentives in ACO contracts?
  • Will ACOs change the way primary care practices are reimbursed?
  • Will ACOs place new care management resources into current primary care practices/infrastructure?
  • How should primary care physician productivity be measured in an ACO model? 
  • How can small primary care practices participate in ACOs, if such practices do not have patient panels large enough to have a stable assessment of risk?
  • What are the optimal ways to align ACO payment incentives between primary care practices, specialists, and hospitals?
  • What proportion of payments to a primary care practice must be non-FFS based in order to incentivize PCMH transformation?
  • Is participation in a single payer PCMH initiative adequate to promote transformation, or will practices only invest in needed PCMH resources once multiple payers are involved.
  • Are current PCMH payment models based on FFS payments and additional capitated management fees viable long term or will such models have to incorporate more risk sharing? How much risk for total cost of care should PCMH practices take on?
  • How should PCMH payment models vary between adult and pediatric practices?

Behavioral Health

Chris Stille, David Keller, Jeremy Ader, Michael Barr, Larry Fricks, Ben Miller, Lisa Lambert

At the 2013 Society of General Internal Medicine Patient Centered Medical Home (PCMH) conference, the behavioral health (BH) workgroup determined a number of research and policy priorities for the coming year regarding the integration of behavioral health and primary care. The workgroup first stressed the importance of defining a number of key terms related to the integrated BH/PCMH.  For example, what does the term behavioral health encompass and which terms do we use to define different levels of integration? Next, we need to gain a much better understanding of the value of various integrated BH/PCMH models (i.e. phone consultations, tele-psychiatry, co-location and integration) and assess their impact on factors ranging from practice culture to the logistics of care delivery.  Furthermore, it is important to look at how these models target special populations, such as people with SPMI and people with chronic conditions and to ensure that the integrated BH/PCMH model reduces disparities by addressing the needs of the most vulnerable populations, such as children and the homeless. 

Policy recommendations from conference:
  • For a policy-relevant research agenda to move forward, consensus must be developed on terms used by researchers, such as “behavioral health” and “integrated care”
  • The most critical, most understudied topic areas tend toward the effects of integrated care on special populations, such as children, the poor and homeless, people with multiple chronic conditions, and people with serious mental illness. Best practices in this area should be evaluated, using common outcomes where possible.
  • Research is needed on the effects of barriers to accessing appropriate mental health services, especially insurance “carveouts” and other features that greatly restrict patient choice of services. Policy and payment initiatives must act to reduce these barriers.
  • Research on optimal composition of mental health teams and the optimal role of patients and families as team members is needed.
  • Most existing research evaluates disease-specific treatments in well-defined specific populations, e.g. depression treatments for the elderly. More is needed on treatments effective across a wide range of conditions and populations. It is likely that new measures will need to be developed to evaluate these treatments.
  • Intervention evaluation should look broadly at the effects of treatments on function and their value to society over a longer term than is typically studied.

Practice Transformation

W. Perry Dickinson, William L. Miller, David M. Keller, Asaf Bitton, James W. Mold

PCMH transformation is an effort to strengthen primary care by adding evidence–based improvements in chronic and preventive care and a greater emphasis on quality and safety, all with a central focus on patient-centeredness and patient engagement. However, many practices have considered PCMH as equivalent to the NCQA PPC-PCMH recognition process (or some other form of PCMH certification). This has proven to be problematic, as many practices have approached their transformation efforts with a project-oriented, check-the-boxes mentality, thinking that once they have achieved recognition, their work is done, despite the fact that few of the changes made are fully sustained or are sufficient to accomplish the deeper goals of transformation. In fact, the term, “transformation,” implies an end-point, whereas achievement of the changes prescribed by PCMH should be a waypoint on an ongoing journey of change and improvement. 

Policy Questions to Consider:
  • What are the optimal framework and sequencing of PCMH and other related practice transformations that will accomplish the changes that are necessary for a high functioning primary care system? Is there a “road map” that can be used as a common vision of where we are going and how we are going to get there?  How should that “road map” be adapted for primary care practices that serve special populations (e.g. pediatrics, geriatrics, women’s health, homeless, underserved populations, incarcerated persons, adolescents)?
  • What method or combination of methods for supporting practice transformation result in successful PCMH transformation and improved practice change capacity? PCMH and related practice changes are challenging to implement, both because they cause critical changes to relationships, work flows, and communication patterns and because of the competing demands affecting practices. Research is needed to define optimal models and approaches to facilitation and how to match facilitation methods and dosing to targeted changes to most efficiently accomplish practice transformation. 
  • What are the costs associated with practice transformation to become medical homes, and what are the models for covering such costs? What funding and other resources are necessary to achieve the changes that we want? Which stakeholders (payers, purchasers, health systems, hospitals, or providers) should pay for transformation?  How do these resource implications change for special populations (e.g. geriatrics, child health, underserved populations)?
  • Patient and family engagement, in the design of care and in their own care, is possibly the most transformative part of our reconceptualization of primary care and the health care system, with a shift from doing things “to” patients/families to do things “with” them in the transformation journey. What is the value of incorporating patients and families more deeply into the redesign process and governance of the transformed practice? 
  • The inadequate availability of the data necessary to drive practice improvement has been an ongoing disappointment. Despite continued adoption and use of electronic health records (EHRs) in primary care practices, the availability and use of data from EHRs for patient care has, so far, fallen far short of expectations.  How can we overcome the barriers caused by inadequate availability of data to guide practice transformation, quality improvement, population management, and other PCMH aspects? What should the EMR, HIE, and other health information technology tools of the future look like?  Data are the lifeblood of effective medical homes and accountable care organizations, which are unlikely to be fully successful without improvements in this area.

Workforce Issues

Preston Reynolds, Larry Green, Kathleen Klink, David Keahey, Russ Phillips, Gordon Schectman, Scott Shipmann, Kathy Rugen. Molly Davis 

The Patient-Centered Medical Home (PCMH) is a practice model where clinical care is provided by coordinated inter-professional teams of healthcare professionals with the overarching goal of delivering the right care to patients, by the right professional, at the right time, in the right setting, for the right cost. In principle, all clinical care should be delivered with these goals and optimally in the PCMH structure. The PCMH rests first on health professionals’ absolute clinical competence in their individual disciplines as well as team competencies. For widespread adoption of the PCMH to occur, the country must engage in serious conversation about the health professionals who are needed for these teams; what training they must complete individually and collaboratively to ensure discipline and team-based competence, and how and when learners and clinicians should be evaluated to ensure competence for PCMH practice. Who, What, How and When are at the heart of our discussion about workforce.  

To date, the Veterans Health Administration is the largest health care delivery system to implement a PCMH model known as the Patient Aligned Care Team (PACT), and has led fundamental change in health professions education.  Through substantial financial and time investments, current practitioners are trained to achieve and maintain the competencies required to implement team-based care with the goal of delivering all care in the PCMH model. 
The PCMH Workforce Workgroup identified a wide range of issues that will need to be addressed as part of broader adoption of the PCMH that include: 
  • identification of foundational competencies for all health professionals involved in the PCMH; 
  • determination of the  appropriate health professionals for the PCMH; 
  • development of strategies to place patients in the center of PCMH care delivery; and 
  • establishment of financial incentives to support education and practice transformation to ensure all health professionals obtain discipline-specific and team-based skills.   
  • The PCMH Workforce Workgroup recommends policy changes in five areas that include: 
  • Conceptual redefinition of what constitutes a PCMH;
  • Ensuring the educational needs of trainees and practicing clinicians are met in the immediate future and on an on-going basis; 
  • Addressing needs of leadership to align vision and mission; 
  • Working with local, statewide, regional, and national care delivery systems to address workforce needs to ensure care of all patient populations; and 
  • Identifying and continuously monitoring local needs to optimize community engagement and to achieve improvement in population health. 
Conceptual:  Expand the concept of primary care beyond “Continuous, Comprehensive, and Coordinated” to embrace the need for engagement with patients and communities to achieve individual and population desired health outcomes.    

Education and Training:  Fundamental restructuring and redesign of health professions education must occur to train the professional workforce across disciplines and equip them with the essential competencies to work effectively in PCMH models of care delivery.  All health professionals must achieve excellence in their discipline-specific knowledge and skills, as well as competence in skills essential for inter-professional team-based care.  These newly defined competencies should be compatible with accreditation standards for each health professions discipline, including Accreditation Council on Graduate Medical Education (ACGME) Milestones, American Osteopathic Association (AOA), Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), the Commission on Collegiate Nursing Education (CCNE), and the Commission on Dental Accreditation (CODA) in order to facilitate transformation of pre-doctoral, doctoral and graduate training.  Faculty development to ensure modeling of inter-professional care and education should be prioritized along with development of new learner-assessment evaluations.  These evaluations of both trainees and faculty should reinforce discipline-specific competence as well as team-based training with a focus on the patient, including measureable outcomes. Essential to all health professions training must be knowledge and skills in cultural competence, promotion of diversity and reduction of health disparities. 

Implementation:   Payment incentives must be implemented so that administrative and clinical leaderships’ vision is aligned and shifted from the single patient encounters to a system based approach. The goal is to move from individual-only health to consideration of population health with a focus on improved access and reduced health disparities.

Macro:  Statewide, regional and national initiatives should be developed to ensure geographic distribution of a diverse, values driven workforce equipped with organizational, leadership, communication, health promotion, quality improvement and population-oriented skills. This workforce should strive to achieve the Triple Aim of better health, better care and better value.  It is anticipated that there will be development of new financial models to support such systems-wide transformation. 

Local:  Local population needs assessments should be conducted to determine how best to optimize adoption of the PCMH. Needs assessments should include language and cultural barriers, community resources, such as lay health workers and knowledgeable patients and family members and other potential creative solutions to maximize community engagement, combining primary care and public health approaches.

Systems Improvement: Data should be collected along the continuum of PCMH adoption to create a culture of continuous quality improvement.  These data should capture health outcomes, trainee, provider and patient satisfaction, as well as expenditures and payments.  

  1. AAFP, AAP, ACP, AOA. Joint Principles for the Medical Education of Physicians as Preparation for Practice in the PCMH, December 2010
  2. Takach M. About half the states are implementing Patient-Centered Medical Homes for their Medicaid populations. Health Affairs 2012;31:2432-40
  3. Klein S. The Veterans Health Administration: implementing patient-centered medical homes in the nation’s largest integrated delivery system. Commonwealth Fund pub. 1537. Sept. 2011.
  4. Schmitt MH, et al. The coming of age for interprofessional education and practice.  Amer J Med 2013:126:284-88.
  5. Wynia MK, Von Kohorn I, Mitchell PH.  Challenges at the intersection of team-based and patient-centered health care. JAMA 2012;308:1327-28.
  6. Carney PA, et al. Assessing the impact of innovative training of family physicians for the patient-centered medical home. J Grad Med Educ 2012;16-21.
  7. Saultz JW, et al. Medical student exposure to components of the patient centered medical home during required ambulatory clerkship rotations: implications for education.  Acad Med 2010;85:965-73.
  8. Advisory Committee on Training in Primary Care Medicine and Dentistry.  The Redesign of Primary Care with Implications for Training. Eighth Annual Report 2010.
  9. The Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice May 2011. 
  10. Keahey, DJ, Dickinson P, Hills K, et al. STFM/PAEA Joint Position Statement Workgroup. Educating Primary Care Teams for the Future: Family Medicine and Physician Assistant Interprofessional Education. J Phys Assistant Educ 2012;23:18-26.
  11. Carney PA, Eiff PM, Green LA, et al. Preparing the personal physician for practice (P4): site-specific innovations, hypotheses, and measures at baseline. Fam Med 2011;43:464-71.
  12. Jackson EG, et al. the Patient-Centered Medical Home: A Systematic Review. Ann Int Med 2013;158:169-78.
  13. National Organization of Nurse Practitioners Faculties. Nurse Practitioner Core Competencies. Amended 2012.
  14. Green LA, Pugno P, Fetter G, Jr., Jones SM. Preparing the personal physician for practice (P4): a national program testing innovations in family medicine residencies. J Amer B Fam Med 2007;20:329-31.
  15. Green LA, Jones SM, Fetter G, Pugno P. Preparing the personal physician for practice: changing family medicine residency training to enable new model practice. Acad Med 2007;82:1220-27.
  16. Change A, Bowen JL, Buranosky RA, et al. Transforming primary care training – patient-centered medical home entrustable professional activities for internal medicine residents. JGIM Sept. 2012  Published online. 
  17. Cox M, Naylor M, et al.  Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign, available at:
  18. Rosland, A, Nelson K, Sun, H, Dolan ED, Maynard C, Bryson C, Stark R, Shear JM, Kerr E, Fihn SD, & Schectman G. (2013).  The patient-centered medical home in Veterans Health Administration.  The American Journal of Managed Care e263-e272.

Patient and Family Engagement 

Beverly Baker, Crystal Cene, Beverly Johnson, Nora Wells, Renee Turchi

Various definitions exist for patient and family engagement,1-3 while differing slightly, all articulate the importance of: 
  • Partnerships among patients, family members, and health care providers; 
  • Patients and family members being viewed as essential members of the health care team;
  • Valuing and using patient and family expertise, insights, and perspectives in the design, implementation, and evaluation of programs and policies.
Operationalizing engagement and evaluating the effectiveness and impact of strategies designed to enhance engagement has been challenging. Central to this challenge are differences in how these terms are understood in the adult and child health arenas and the need for consensus on what aspects of “patient and family engagement” are most important to measure.  While the term, “patient and family engagement” is often shortened to “patient engagement,” we believe it is imperative to be explicit and consistent in the inclusion of the word “family.” Families are key to promoting health and wellness, managing chronic and complex conditions, and assisting with transitions and ongoing care for the care of patients of all ages. Systems need to be in place in primary and specialty care practices and across the continuum of care encouraging and supporting patients to define their family and how they want them involved in care. 

Some evidence exists demonstrating the impact of engaging families in pediatric and adult health care. Undoubtedly, families are highly relevant to health and healthcare. Family engagement in care influences the content and dynamics of the medical encounter and possibly impacts quality of care delivered to patients. 

The patient and family centered medical home has as one its guiding principles the coordination and facilitation of care between patients, their physicians, and family members.4  While more research is needed, family engagement appears to represent a “hidden resource” for improving the quality of care delivered to adult patients and particularly with patients who are older, vulnerable, and or have a chronic illness. Even though there is little empirical research, the Institute of Medicine in its 2012 Report: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America,38 stated as its 4th of ten recommendations: 

“Involve patients and families in decisions regarding health and health care, tailored to fit theirpreferences. Patients and families should be given the opportunity to be fully engaged participants at all levels, including individual care decisions, health system learning and improvement activities, and community-based interventions to promote health.” 5

The workgroup identified several models and emerging best practices and models for patient and family engagement in direct care, in primary care redesign, and improvement. In addition, the workgroup identified several research agenda items and policy recommendations: 

  • Support education of patient and family engagement in direct care and monitor the impact on health outcomes and utilization, patient and family satisfaction, and patient safety.
  • Provide education and support strategies for physicians and staff to encourage and support patient and family engagement in direct care and measure impact on staff and clinician satisfaction, staffing, cost efficiency, and time.
  • Encourage and support patient and family engagement in primary care redesign and improvement, including training for families and health care personnel
  • Provide support for patient and family engagement in research via engaging families  n the development of measurement tools, design of measurement protocols, carrying out of research studies, and interpreting and disseminating of results

1 Carman KL, Dardess P, Maurer M, Sofaer S, Adams K. Bechtel C, Sweeney J. Patient and family engagement: A framework for understanding the elements and developing interventions and policies. Health Affairs. 2013; 32(2): 223-231.
2 American Hospital Association. Engaging health care users: A framework for healthy individuals and communities. Chicago: American Hospital Association, 2012 Committee on Research, Benjamin K. Chu and John G. O’Brien, co-chairs. January, 2013.
3  Minniti M, Abraham M. Essential allies—Patient, resident, and family advisors: A guide for staff liaisons. Bethesda, MD: Institute for Patient- and Family-Centered Care. 2013.
4 American Academy of Family Physicians Policy. 2009 COD.
5 Institute of Medicine. (2012). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. S-23 

Health Disparities 

Anne Beal , JudyAnn Bigby, Crystal Cene, Tina Cheng, Robert Nocon, Monica Peek, Shin-Ping Tu

Minorities have less access to high quality primary care and among those with access to the same care providers, minorities often suffer from worse quality of care than non-minorities. The Patient Centered Medical Home (PCMH) emphasizes targeting care toward the individualized needs of patients. Insofar as the PCMH represents higher quality primary care, improving access to the PCMH among minority patients may improve the ability of providers to ensure equitable care to all their patients and reduce disparities. The PCMH “whole-person” orientation also allows for improved links between medical providers and resources to address social factors that are major drivers of health care disparities and/or interfere with individuals’ ability to engage in health care.

For the 2013 Society of General Internal Medicine Patient Centered Medical Home (PCMH) Research Agenda conference, the Health Disparities workgroup determined a number of research and policy priorities to address health disparities and primary care. To this end, the workgroup first examined the literature on PCMH and health disparities and found that there were no recent literature reviews focusing on the PCMH and disparities. Most existing relevant studies (non-commentaries) are cross-sectional analyses of national children’s surveys that report correlates of access to medical-home-like care (n=17). Few rigorous studies which have examined the effectiveness of the PCMH report the race and ethnicity of patients. 

To facilitate discussions on health disparities and PCMH research priorities, workgroup members noted the need for a framework. The workgroup decided on using domains from the 2011 National Committee for Quality Assurance PCMH standards to identify potential approaches to reducing disparities as well as persisting gaps. In-depth discussions of particular examples from the PCMH domains and/or disparity helped to refine potential research and policy priorities.
Research in the context of the PCMH should reflect the current status of what is known about specific interventions to eliminate health and health care disparities among racial and ethnic minority populations.  How to best translate these research findings to the PCMH is an important opportunity to test what we have learned from disparities research.

For more information, contact Leslie Dunne, SGIM.