Rhode Island Office of the Health Insurance Commission: Patient Centered Medical Home Definition

The Rhode Island Office of the Health Insurance Commission (OHIC) is in the process of developing a three part definition and evaluation process for what primary care practices will need to demonstrate to be considered a PCMH in Rhode Island and eligible for infrastructure payment.

While the PCMH definition and evaluation processes are under review, the basic tenets of the definition are likely to include:

• Practice is participating in a formal transformation initiative (i.e., CTC-RI, PCMH-Kids or a payer-sponsored program) and/or practice has obtained NCQA Level 3 recognition. 
• Practices demonstrate meaningful performance improvement over an annual two-year look back period.
• Practice has implemented the following specific cost-containment strategies: 
  • develops and maintains high-risk patient registry;
  • implements care management, focusing on high-risk patients and interventions that will impact ED and inpatient utilization;
  • implements behavioral health integration strategies to improve access to behavioral health services;
  • expands access to services both during and after office hours;
  • develops referral protocols informed by cost and quality data provided by payers; and
  • develops/maintains an avoidable ED use reduction strategy.

OHIC has developed a draft outline of the evaluation criteria it is considering for successful implementation of cost-containment strategies at the practice level and is seeking input on that criterion. The Practice Self-Assessment tool can be found here.  Primary care practices are invited to comment of the criteria and feedback can be sent to: [email protected]