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
• Behavioral Health
• Practice Transformation
• Workforce Issues
• Patient and Family Engagement
• Health Disparities

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.