Patient-Centered Medical Home and Quality Measurement in Small Practices
Published Online: June 25, 2014
Jason J. Wang, PhD; Chloe H. Winther, BA; Jisung Cha, PhD; Colleen M. McCullough, MPA; Amanda S. Parsons, MD, MBA; Jesse Singer, DO, MPH; and Sarah C. Shih, MPH
The patient-centered medical home (PCMH) concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions.1-3 This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the shortcomings of the current healthcare system.4
Components of the PCMH model include practice-based policies and processes intended to improve healthcare quality, patient experience, clinician satisfaction, and costs of care.5 Pilots and demonstration projects have yielded mixed results, but positive reports associate PCMHs in large practices and institutions with decreases in costs for patients enrolled in Medicaid; increased care of Medicaid patients; and positive patient and clinician experiences.6-8 Recently published studies have also shown that components of the medical home (eg, care coordination, pre-visit planning) are associated with positive effects on clinical outcomes for patients and quality of life for clinicians.9,10
The process of transforming and achieving recognition as a medical home can be difficult, especially for small practices with few resources.11,12 Additionally, small practices located in low income neighborhoods face challenges unique to their settings (eg, smaller panel size for quality measurement, lack of information systems, and lack of support staff) which can further exacerbate their ability to generate the documentation needed to demonstrate transformation and meet the standards for recognition.13 Promoting the adoption of PCMH standards in small primary care practices in lower income neighborhoods with a large proportion of chronically ill patients can be advantageous for reducing healthcare inequalities.14
As part of a larger public health initiative, the Primary Care Information Project (PCIP), a bureau within the New York City Department of Health and Mental Hygiene, has offered assistance to small, independent practices in New York City to complete the application for the National Committee for Quality Assurance’s (NCQA’s) Physician Practice Connections–Patient Centered Medical Home (PPC-PCMH) recognition program.15 This study assesses the clinical quality outcomes of PCIP-participating practices that have achieved PPC-PCMH recognition from NCQA, and compares performance on quality measures from 2009 through 2011 in practices that have been PCMH-recognized with those that have not.
In an effort to transform primary care and improve population health, PCIP assists primary care practices in the adoption and use of electronic health records (EHRs). From its inception in 2005 through early 2012, PCIP assisted over 3000 primary care clinicians located in over 600 independently owned practices to adopt preventionoriented EHR systems. Collectively, PCIP participants represent over 20% of New York City’s primary care clinicians and serve approximately 2.6 million patients.16
Recognizing that digitizing the information around healthcare alone would not bring about the changes needed to improve the delivery of clinical preventive services, PCIP offers additional support to address both technical needs and quality improvement (QI).17 PCIP employs a field team dedicated to assisting clinicians in optimizing work flows and leveraging data from their own EHR systems to track clinical quality performance. Much of the QI curriculum was modeled around the standards articulated by the NCQA’s PPC-PCMH program. This included an initial visit to identify practice leadership or champion for QI activities; follow-up meetings with the practice or provider to review progress on meeting QI objectives; using the functions within the EHR, such as the registry tool that generates lists of patients by selected characteristics (eg, diagnosis of hypertension with blood pressure over 140/90 mm Hg without a visit to practice in past 6 months and no scheduled visit in next 3 months); and reviewing the quality reporting tool—a specific feature within eClinical- Works co-developed with PCIP to display quality measures tied to the city’s health policy agenda.18 PCIP offered visits to practices every 4 to 6 weeks; staff were available by e-mail and phone to answer questions in addition to the on-site visits.
To encourage and facilitate the PPC-PCMH recognition process, PCIP established a multi-site application and offered to practices the ability to apply under the 2008 standards. Fees for the application were also subsidized by PCIP. Because some of the PCMH standards had been met across all PCIP practices, such as having an EHR with clinical decision support, clinicians did not have to repeat some of the standard documentation related to their EHRs in their NCQA applications. PCIP practices eligible to be included in the multi-site application were eligible to receive 36.75 points, which at the time was adequate for obtaining Level 1 recognition. However, all practices still needed to provide supporting documentation to demonstrate to NCQA their use of the systems; if practices wished to do so, they could work towards a higher recognition level by submitting additional documentation. NCQA then reviewed the documentation gathered by practices and submitted by PCIP to determine whether clinicians in the application met Level 1, 2, or 3 PPC-PCMH standards. By early 2012, PCIP had assisted roughly 25% of its member practices in achieving NCQA recognition, including 269 sites representing 169 practices and 657 clinicians to meet 2008 standards. Practices applying for PPC-PCMH recognition after July 1, 2012, are required to follow 2011 standards.
Primary care practices were included in this analysis if they had 5 or fewer clinicians and adopted the eClinicalWorks EHR system prior to October 2009. Pediatricfocused practices were excluded as the quality measures analyzed were limited to adult primary care. Practices were also excluded if data were unavailable for either of the 2 analysis periods: October 2009 and October 2011. Because the process of obtaining NCQA recognition can take between 6 to 12 months, practices were categorized into the PCMH-recognized group if they achieved NCQA recognition at any time up until February 2012.
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