At the 2018 PCMH Congress, healthcare providers from all practice sizes shared their strategies for successfully operating as a patient-centered medical home (PCMH). Providers shared a number of simple steps that practices can take to adopt and sustain PCMH operations. To note, any practice can implement these strategies to improve practice workflows, not only PCMH practices.

HOW TO: OPTIMIZE PRE-VISIT PLANNING

Operating as a PCMH requires coordinating care for an entire patient panel (all screenings, outstanding orders, and other patient-specific needs). Efficient pre-visit planning ensures providers maximize time spent with patients and minimize gaps in care.

• A large health system built a “patient snapshot” in their electronic health record (EHR). Running this simple report compiles patient information from different areas of the chart, which allows the care team to see at a glance various issues such as missing colonoscopies or screenings. Reviewing this “snapshot” during pre-visit planning saves time and improves patient satisfaction.
• A pediatric practice delegates pre-visit responsibilities to care team members. Front desk staff prepare charts; medical assistants review outstanding orders, enter immunization data, and review quality gaps and care plans. The team reviews pre-visit planning information together in their daily huddle.

HOW TO: ALIGN PROGRAMS

Practices can integrate PCMH activities with other program requirements to minimize the overall administrative workload that comes with participating in multiple programs.

• A community development financial institution shared how practices use PCMH workflows to meet requirements for the NY Medicaid EHR Incentive Program (Meaningful Use) and the Merit-Based Incentive Payment System’s Promoting Interoperability performance category, and align PCMH workflows to qualified entity (or regional health information organization) workflows.
• A large health system seeks opportunities to connect PCMH workflows to revenue. For example, its providers may bill Medicare for Transitional Care Management after completing a PCMH-required post-hospital follow-up visit, and ensure that the PCMH-required patient outreach targets the HEDIS measures tied to incentives.New York State (NYS) PCMH supports providers with connecting to a qualified entity, which eases access to the specialist and hospital information required for meeting program objectives related to care transitions.

HOW TO: INTEGRATE BEHAVIORAL HEALTH

One health system found that having a behavioral health clinician on the primary care team improves patient and provider satisfaction, reduces the stigma associated with behavioral health conditions, and improves behavioral health outcomes.

HOW TO: PERFORM RISK STRATIFICATION

Whole-practice risk stratification (assigning a risk level to each patient and choosing interventions for each risk level) is a new NYS PCMH requirement. It is also a key component of meeting value-based payment arrangement requirements.

• A small practice in Ohio that uses eClinicalWorks determines patient risk level with the input of the entire care team. The practice assigns risk levels for each day’s patients in daily team huddles to manage urgent appointments and prioritize patients with higher risk scores.
• A healthcare consulting group uses patient data when possible. The group suggests determining risk level by prioritizing certain conditions, such as diabetes or hypertension, then analyzing EHR data, such as lab results, alongside hospitalization information.
• A regional health system integrates risk stratification with Medicare’s Chronic Care Management (CCM) program, which reimburses providers for out-of-visit services such as following up with patients by phone and tracking down lab results. As part of its stratification process, the system began providing CCM services to its highest-risk patients, who benefit most from care coordination support.
• A pediatric organization considers social determinants of health, including living conditions and food access, when assigning risk levels.

HOW TO: SUSTAIN OPERATIONS

Daily PCMH activities, such as holding care team huddles, quickly become habit for a practice. Practices may find it more difficult to keep up with monthly or quarterly activities, such as holding quality meetings or re-assessing performance on utilization measures.

• A hospital association recommended creating and adhering to a schedule for all intermittent activities to remain on task.
• A pediatric center made PCMH a permanent standing item on departmental meetings to ensure that all department contacts continue to discuss and optimize PCMH operations, even after achieving PCMH Recognition.

These recommendations are only a sample of the many effective strategies for optimizing practice workflows. Contact NYC REACH at pcmh@health.nyc.gov to learn more.