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The American Journal of Accountable Care June 2018
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Amazing Grace: A Free Clinic's Transformation to the Patient-Centered Medical Home Model
Jason Alexander, BS, PCMH CCE; Jordon Schagrin, MHCI, PCMH CCE; Scott Langdon, BA; Meghan Hufstader Gabriel, PhD; Kendall Cortelyou-Ward, PhD; Kourtney Nieves, PhD; Lauren Thawley, MSHSA; and Vincent Pereira, MHA, PCMH CCE
The Intersection of Health and Social Services: How to Leverage Community Partnerships to Deliver Whole-Person Care
Taylor Justice, MBA, President of Unite Us
Case Study: Encouraging Patients to Schedule Annual Physicals
Nicholas Ma
Effects of an Integrated Medication Therapy Management Program in a Pioneer ACO
William R. Doucette, PhD; Yiran Zhang, PhD, BSPharm; Jane F. Pendergast, PhD; and John Witt, BS
Are Medical Offices Ready for Value-Based Reimbursement? Staff Perceptions of a Workplace Climate for Value and Efficiency
Rodney K. McCurdy, PhD, and William E. Encinosa, PhD
Utilizing Community Resources, New Payment Models, Technology to Deliver Accountable Care
Laura Joszt, MA
Cost-Effectiveness of Pharmacist Postdischarge Follow-Up to Prevent Medication-Related Admissions
Brennan Spiegel, MD, MSHS; Rita Shane, PharmD; Katherine Palmer, PharmD; and Duong Donna Luong, PharmD

Amazing Grace: A Free Clinic's Transformation to the Patient-Centered Medical Home Model

Jason Alexander, BS, PCMH CCE; Jordon Schagrin, MHCI, PCMH CCE; Scott Langdon, BA; Meghan Hufstader Gabriel, PhD; Kendall Cortelyou-Ward, PhD; Kourtney Nieves, PhD; Lauren Thawley, MSHSA; and Vincent Pereira, MHA, PCMH CCE
Despite many barriers, Grace Medical Home, a free clinic, achieved patient-centered medical home recognition in October 2014 through a focused team-based approach.

Grace Medical Home is a faith-based organization with a mission of providing the highest quality of care possible to the medically underserved in the central Florida region. One of Grace’s objectives since it started seeing patients in 2010 was to transition its primary care clinic into a fully functioning patient-centered medical home (PCMH) recognized by the National Committee for Quality Assurance. Many potential barriers limited Grace, especially that it is a free clinic that operates primarily on donations and is staffed mostly by volunteers. Despite these and other limitations, Grace managed to achieve PCMH recognition in October 2014 through a focused team-based approach and hands-on guidance from a Regional Extension Center’s PCMH team. Grace was 1 of 10 free clinics that achieved PCMH recognition at that time. Currently, there is limited published information about free clinics transitioning to the PCMH model.

The American Journal of Accountable Care. 2018;6(2):30-35
A patient-centered medical home (PCMH) is a care delivery model that pursues care delivery improvement through primary care services. The PCMH model was designed to meet patient needs, increase access to care, and enhance overall quality, all while being more cost­-efficient. In 2007, multiple primary care associations collaborated to develop the Joint Principles of the Patient-Centered Medical Home, which established a comprehensive primary care model for children and adults.1 As it relates to medical expenditures, empirical study results show that PCMHs help control costs by optimizing patient access and population health management, which reduces costly hospital and emergency department visits.2 With recent value-based payment models being implemented, a delivery system that focuses on primary care and prevention is key to helping achieve the goals of the healthcare Triple Aim: improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare.3 PCMHs provide continuous, comprehensive care to patients, who build personal relationships with their care providers, including nurse practitioners and physician assistants.4 Predominantly, PCMHs use a team-based delivery model usually led by a primary care provider.5 However, this model is also attractive to nontraditional methods of healthcare delivery, including free clinics.6-9 The National Committee for Quality Assurance (NCQA) has a recognition program that is the most widely adopted PCMH evaluation program in the United States. Most PCMH transformations occur following the NCQA standards,10 because the NCQA closely aligns practice transformation into a PCMH with achieving the Triple Aim and lends itself to high-quality care delivery. This has captured the attention of healthcare stakeholders, including providers, policy makers, and purchasers. The goals of this paper are to highlight activities associated with PCMH transformation, inform readers about how a free clinic mitigated barriers and motivated drivers, and describe lessons learned during this transition.

An Overview of Grace Medical Home

In 2008, Marvin Hardy, MD, founded Grace Medical Home (“Grace”), a nonprofit free clinic located in Orange County, Florida. Soon after, Kirsten Carter, MD, an Orlando internal medicine physician, joined Hardy in his journey to open Grace’s doors. The majority of Grace’s funding comes from private donors. Grace has a small staff of paid employees and many clinical and nonclinical volunteers. The clinic operates under a holistic model of care, providing a host of onsite ancillary services, including nutrition counseling, pharmacy, laboratories, x-rays, and mental health counseling, all of which lend themselves to supporting the PCMH model. The clinic serves more than 3000 patients in central Florida, all of whom do not qualify for Medicaid but cannot afford private insurance. The eligibility criteria include currently living in Orange County, Florida, for at least 2 months; earning less than 200% of the federal poverty line; being uninsured; being 65 years or younger; and being employed (currently or in the last 6 months), a full-time student, or a single parent. The population of Orange County is 1.2 million residents, 25% of whom are uninsured.11 The county is approximately 70% white and 23% black, and 30% identify as Hispanic.10

Health information technology (IT) and engaged teams of medical professionals help patients become more involved with their own healthcare. The decision for Grace to pursue PCMH transformation and NCQA recognition was driven by the model’s positive impact on population health needs.

Starting the PCMH Transition

Regional Extension Centers (RECs) are organizations originally funded under the Health Information Technology for Economic and Clinical Health Act (HITECH) to support specific healthcare providers with the implementation of electronic health record (EHR) systems. Building on this business model, some RECs now promote the progression of innovative health IT and the adoption of best practices throughout the medical community. This expansion of services has extended to assisting with the transformation of healthcare delivery systems.

One of the requirements within HITECH was that RECs should create sustainability plans for continuous operation once the original funding had been exhausted. The REC at the University of Central Florida’s College of Medicine chose to implement PCMH transformation and recognition as one of several additional services to continue to assist providers in the central Florida community, with Grace presenting particular challenges due to its status as a free clinic. The REC established a program that focused on PCMH transformation using change concepts, Plan-Do-Study-Act (PDSA) improvement activities, and robust measurement. It also established a core team of NCQA PCMH Certified Content Experts to provide the practice support necessary to making substantive changes in a clinical setting.

In 2013, Grace began its PCMH transformation with the assistance of the REC. Initially, the project experienced a slower-than-anticipated start due to a variety of factors, including staffing resources and other pressing priorities that go with running a free clinic. Eventually, however, Grace leadership worked closely with the REC team and engaged key Grace clinical leaders (3 physicians and 1 nurse practitioner, all specializing in family medicine and pediatrics) to spearhead Grace’s PCMH transformation.

Achievements for NCQA Recognition

Grace earned NCQA recognition under the PCMH 2011 version of the standards and guidelines.12 To achieve this PCMH transformation, a practice must satisfy, at a minimum, the following 6 “must-pass” elements: (1A) access during office hours, (2D) use data for population management, (3C) care management, (4A) support​ self-care process, (5B) referral tracking and follow-up, and (6C) implement continuous quality improvement.

These 6 elements are the core PCMH activities and the baseline requirements for NCQA recognition, but practices must satisfy many other requirements under the PCMH standards and guidelines. Moreover, Grace’s achievement of PCMH recognition indicates that the practice delivers patient-centered care through these PCMH activities despite the challenges of providing this model of care in the environment of a free clinic.

Grace’s approach to satisfy each of the basic elements, although not unique, was based on the realities of its limited resources and staffing model. Grace’s small core staff relies on the volunteer providers who donate their time and effort to see patients. These providers typically volunteer several days a month, and Grace has formed relationships with them so that the time donated is consistent and routine. This unique way of providing patient care made satisfying element 1A, access during office hours, challenging, but Grace demonstrated that it monitors patient access through same-day appointment availability and timely responses to patients by phone. Despite its limited resources, Grace invested in and implemented an EHR system within its clinic, which allows it to use evidence-based guidelines to follow up with patients regarding their care needs (eg, element 2D, use data for population management). Grace demonstrated the ability to monitor gaps in patient care needs by service care type and to develop a follow-up reminder process to contact patients and schedule them for appointments. The uninsured patients at Grace often present with complex chronic conditions, likely as a result of not having access to proper medical care for long periods of time. Therefore, it was important for these patients that Grace satisfied element 3C, care management, by collaborating with the patients and their families regarding the development of the care plan for the patient. Satisfying element 4A, support self-care process, implies that Grace equips its patients with resources and education to help patients and their families manage patient conditions. Grace also faced a challenge in providing specialist care for its uninsured patients and had to work to develop a network of community specialists who would evaluate and treat these patients. Grace developed a Care Coordination Department that managed all referrals to these community specialists and made sure that the specialists had all of the information necessary to provide care for the patients, thereby satisfying the PCMH requirements of element 5B, referral tracking and follow-up. Finally, Grace’s overall PCMH transformation demonstrates completion of PCMH element 6C, implement continuous quality improvement, in that it established goals based on its performance measures for care delivery and patient experience on an ongoing basis. Grace continues to work to improve performance on these important clinical and patient experience measures.

Grace faced challenges with the must-pass elements and some of the additional requirements that are needed to achieve PCMH recognition due to its clinic model and the patient population it serves. Working in collaboration with the REC, Grace put forth the effort to refine its processes, develop policies, and implement best practices that would demonstrate how its unique model of care could be highlighted to support PCMH recognition.

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