Helping safety net practices become high-performing patient-centered medical homes

The challenge

Patients and families deserve care that is safe, effective, efficient, equitable, patient-centered, and timely. In their landmark 2001 report, Crossing the Quality Chasm, the Institute of Medicine identified these aims as essential priorities for health care. Action to improve the quality of care is essential to achieving these aims, and the need is urgent.

The Patient-Centered Medical Home (PCMH) is a model of primary care delivery that has the potential to improve clinical quality, patient experience, and reduce health system costs. In PCMH practices, patients receive well-coordinated services and enhanced access to a care team. Providers practicing in PCMHs use decision support tools, measure their performance, engage patients in their own care, and conduct quality improvement activities to address patients' needs. 

In May 2008, The Commonwealth Fund, Qualis Health (now Comagine Health), and the MacColl Center for Health Care Innovation (now the ACT Center) initiated a 5-year demonstration project to help primary care safety net sites become high-performing PCMHs and achieve benchmark levels of quality, efficiency, and patient experience. The goal of the Safety Net Medical Home Initiative (the Initiative) was to develop and demonstrate a replicable and sustainable implementation model for medical home transformation and to help 65 primary care safety net sites in 5 states become high-performing patient-centered medical homes.

The work

The Initiative received applications for participation from 42 organizations in 31 states. Five "Regional Coordinating Centers" were selected, and each partnered with 10 to 15 primary care safety net sites in their respective states: Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. These collaboratives received funding from the Initiative to support practice coaches ("Medical Home Facilitators"), as well as technical assistance, resources, and tools on practice redesign topics such as enhanced access, care coordination, and patient experience.

What we learned

Based on a literature review and advice from a technical expert panel, practices undertook a sequence of 8 changes that built on one another and led to improved care.  These changes were tackled in four stages: 

• Laying the Foundation: Engaged Leadership and Quality Improvement Strategy 
• Building Relationships: Empanelment and Continuous and Team-Based Healing Relationships 
• Changing Care Delivery: Organized, Evidence-Based Care and Patient-Centered Interactions 
• Reducing Barriers to Care: Enhanced Access and Care Coordination 

By the end of the project, most participating safety net clinics had made substantial progress:

• All 65 participating safety net demonstrated some level of implementation for each of the key PCMH changes.
• More than 80% of participating clinics earned NCQA PCMH recognition — in many cases qualifying them for enhanced payments from various payors.

Impact

The Initiative developed a framework for PCMH transformation, the "Change Concepts for Practice Transformation," and published a library of resources and tools to help practices understand and implement the PCMH Model of Care. All these materials are publicly available on the Safety Net Medical Home Initiative website. The site provides access to implementation guides, assessment tools, presentations, and other materials on the change concepts, as well as resources on payment and recognition.

The team also produced a widely-used assessment tool, the Patient Centered Medical Home Assessment, or PCMH-A, which was an extension of earlier MacColl assessments such as the Assessment of Chronic Illness Care, or ACIC, developed for Improving Chronic Illness Care.

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