Patient centered medical home model

               By the end of 2013, it's estimated that 25 percent of health centers will achieve PCMH status.

The patient centered medical home (PCMH) was designed as a way to improve health by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a PCMH as a model of the organization of primary care that delivers the core functions of primary health care.

The concept of a PCMH is more than forty years old. As originally developed by the American Academy of Pediatrics, it described a pediatric practice that would coordinate all of the care for children with multiple medically complex problems, including birth defects, developmental disabilities, chronic diseases such as cystic fibrosis, muscular dystrophy, and the like. Recently, the PCMH has been revitalized as a concept by the American College of Physicians, the American Academy of Pediatrics, and the American Association of Family Physicians. The impetus for revisiting the concept was the desire to find a way to have primary care physicians paid for developing infrastructure to coordinate care more effectively.

There are now thousands of PCMH projects across the country. Typically, they involve primary care practices which generate a far higher level of engagement with their patients and coordinate care for them across other providers. In many ways, the PCMH model is what gatekeepers in HMOs in the mid-90s were supposed to do, but usually did not. One of the major focuses of PCMH practices is around chronic care and keeping patients out of the hospital. There is some data that, in fact, these approaches work. The NCQA and several other organizations accredit PCMHs around a range of structural attributes as well as process measures. These include using electronic records, using evidence-based guidelines, identifying high risk patients, tracking and coordinating care, measuring and improving performance. Typically, primary care physicians are paid an enhanced per-member per-month capitation payment for their PCMH activities.

What’s the difference between a PCMH and an ACO?

The PCMH is an enhanced primary care delivery model that strives to achieve better access, coordination of care, prevention, quality, and safety within the primary care practice. Its aim is to create a strong partnership between the patient and primary care physician. In the PCMH model, payers often reward providers with bonuses for improving primary care services for each patient in the medical home.


The Accountable Care Organization (ACO) is also based around a strong primary care core.  But ACOs are comprised of many “medical homes”—in other words, many primary care providers and/or practices that work together.  Some have even dubbed ACOs the “medical neighborhood.”  The difference is that ACOs would be accountable for the cost and quality of care both within and outside of the primary care relationship.  As such, ACOs must include specialists and hospitals in order to be able to control costs and improve health outcomes across the entire care continuum.  

Where do dermatologists fit within the PCMH model?

Because coordination of care is the essence of the PCMH, dermatologists as specialists would relate to these primary care practices as part of what is being referred to as the “patient centered medical neighborhood.” In fact, NCQA has created a program for PCMH recognition for specialty practices. The first practice so recognized was an oncology practice. 


For dermatologists who depend on some portion of their business from referrals from other practitioners, the significance of PCMH is not to be designated as a PCMH, but to be seen as a medical specialty practice with common values with the PCMH primary care practice, so as to support their goals. In very few instances, the PCMH is paid broader capitation than for primary care alone, so that the primary care practice would be responsible for paying specialists for their care. For most dermatologists, the issues here are not financial, but rather around clinical collaboration. Excellent communication with the primary care practice, cost effective approaches to care, measurement and transparency of results will be what makes a dermatology practice attractive to be part of the PCM neighborhood.

To learn more about NCQA’s Patient-Centered Specialty Practice Recognition and determine whether your dermatology practice can benefit from this new care coordination and management program, visit: http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPracticeRecognition.aspx

How should dermatology practices collaborate with a PCMH?

Measuring your own practice on performance quality metrics that reflect PCMH values and sharing that data with potential PCMH colleagues can be helpful in getting referrals from PCMH practices. Adopting policies that explicitly articulate the dermatology practice’s commitment to PCMH values with respect to patient engagement, clinical collaboration, standardizing to the evidence base, practice measurement, and willingness to communicate more actively can be important. Proactively approaching local PCMH practices to ask what they are looking for in their specialist partners can facilitate more effective communication.

Will a dermatology practice need to have an electronic health record in place in order to collaborate with a PCMH?

While it is not essential for a dermatology practice to have an electronic health record (EHR) to collaborate with the PCMH, an advanced PCMH will likely prefer to collaborate with electronically more advanced practices. Indeed, having an EHR may provide your dematology practice with a competitive advantage as you seek to partner with a PCMH to coordinate and track patient care while measuring and managing performance improvement.

Indeed, having an EHR may provide your dematology practice with a competitive advantage as you seek to partner with a PCMH to coordinate and track patient care while measuring and managing performance improvement. While the transition to EHR can be challenging, and not all software programs are ideal, good adoption results can be obtained saving time for physicians and their practice when they use an EHR. A dermatology practice should also determine how their EHR will communicate with the PCMH’s EHR and whether there are any additional costs for interfacing the two.

What are some things a dermatology practice should consider when educating a PCMH about building a collaborative relationship?

After assessing your local market environment in terms of number of established or soon-to-be established PCMH, and determining their need for partnering opportunities and referral arrangements, you will need to explain the value proposition you are willing to provide the PCMH. To support the relationship between a dermatology practice and PCMH, it may he helpful for the dermatologist to educate their primary care colleagues by providing the dermatology experience and perspective on the following:

  • Skin diseases are commonly complex and often difficult to diagnose and treat; therefore, requiring the PCMH to have appropriate referral guidelines in place to support primary care physicians’ decision-making is critical.
  • Any referral guideline developed for and used by the PCMH should establish clear and helpful referral criteria such as when patients make requests for dermatologic consultation/referrals, when clinical diagnosis is uncertain, or when there is unexpected and/or unexplained change in the course of the disease. At minimum, the PCMH should have access to dermatologists for purposes of consultative care for all patients with significant dermatologic diseases and dermatologists should be able to assume long-term/follow-up relationships when specific treatment is needed, when ongoing procedures are likely to be needed, or when follow-up for a complex or chronic skin disorder is requested.
  • Any referral guideline developed for and used by the PCMH should establish clear and helpful referral criteria such as when patients make requests for dermatologic consultation/referrals, when clinical diagnosis is uncertain, or when there is unexpected and/or unexplained change in the course of the disease.

What should a dermatology practice expect from the PCMH in terms of joining the "neighborhood”?

An advanced, well organized PCMH may well seek a formal affiliation with principles of data sharing and communication documented. However, this is not essential to participating in the PCMH neighborhood. A dermatology practice should expect to communicate clearly and more frequently with PCMH clinicians than occurs when dermatology is conducted in a siloed context, which traditionally may only consist of the initial consult letter sent back to the referring physician.

What are some advantages and disadvantages for dermatology practices to consider before becoming part of a “medical neighborhood” working with a PCMH?

Advantages:

  • Potential preferred referrals solidifying patient stream
  • Clearer understandings regarding both “handoffs” and “handbacks” of patients

Disadvantages:

  • Increased communication expectations
  • Potential changes in record keeping practices
  • Potentially fewer self-referred patients