HIV ACCESS PCMH Demonstration Project:
Home Improvement Bulletin
July 2012

Defining the Patient Centered Medical Home

 

 

Most people who work in health care and public health have heard the term "Patient Centered Medical Home," but it isn't always clear what the term means.  The Patient Centered Medical Home (PCMH) is a model that has garnered national attention in the last several years, in large part because of the passage of the Affordable Care Act (ACA).  The ACA emphasizes prevention, cost savings, and quality of care, all of which are important components of the PCMH model.

 

In a PCMH, care is highly coordinated and efficient, often due to the skilled use of electronic health records.  Access to care is enhanced in various ways in a PCMH--whether through the use of extended hours, telephone or email access to doctors, group visits, or a combination of multiple strategies.  Quality of care is emphasized in a PCMH by using a Continuous Quality Improvement framework for monitoring data and improving patient care.  Perhaps most importantly, patients who receive care at a patient centered medical home are empowered to manage their own health and well-being.  Early evidence shows that the PCMH model is associated with lower costs and a higher quality of care.   

 

Agency for Healthcare Research and Quality (AHRQ), defines a medical home as "a model of the organization of primary care that delivers the core functions of primary health care."  According to AHRQ, the five core attributes of a medical home are:

1) Patient centered

2) Comprehensive care

3) Coordinated care

4) Superb access to care

5) A systems-based approach to quality and safety

 

These attributes loosely correspond to the six elements outlined in the National Commitee for Quality Assurance (NCQA) 2011 PCMH Standards:

1)  Enhance access and continuity

2) Identify and manage patient populations

3) Plan and manage care

4) Provide self-care and community support

5) Track and coordinate care 

6) Measure and improve performance

 

The NCQA uses these standards to award formal "recognition" as a Patient Centered Medical Home to clinics that submit documentation showing that they meet the standards.  The Joint Commission and the Accreditation Association for Ambulatory Health Care also offer accreditation and certification for medical homes.

 

Becoming a Patient Centered Medical Home is a long journey for any health care organization, and the transformation process is much more than just achieving recognition or certification.  The principles of a Patient Centered Medical Home need to become "coded into an organization's DNA" in order for the model to be fully realized.  For a visual representation of how sites move toward realizing the PCMH model, check out our PCMH Implementation Continuum

 

To learn more about the PCMH model and the HIV ACCESS PCMH Demonstration Project please contact Erin Gael Chambers.

Voices from the Field 

We sat down with HIV Panel Manager Patti Wilson, who works at La Clinica de la Raza in Oakland, California. 

 

Click on the video below to hear Patti describe her work and how providers and patients benefit from panel management.

 

Voices from the Field: Patti Wilson
Voices from the Field: Patti Wilson

 

Evaluation Update

 

BTW informing change (BTW) continues their collaboration with HIV ACCESS on the evaluation of the PCMH Demonstration Project. This month they are finalizing the data collection processes, including coordinating their efforts with the cross-site evaluator, the Center for AIDS Prevention Studies (CAPS). BTW will participate in "meet and greet" sessions with the clinics and CAPS to introduce clinic staff to the evaluation team and to discuss any logistical issues around data collection processes at each clinic site. BTW is also in the process of scheduling interviews with clinic staff to launch baseline data collection.

Resource: Linkage Contact List
Linkage Contact List
With recent expansion of HIV testing initiatives in Alameda County, seamless linkages between testing providers and care facilities is more important than ever. In order to better facilitate linkage to care for newly-diagnosed and out-of-care HIV-positive people in Alameda County, HIV ACCESS and the East Bay AIDS Center (EBAC) have created this Linkage Contact List.The list provides direct contact information for HIV service providers, which can help new patients to avoid the delays often caused by seeking appointments through typical scheduling processes at many agencies.
In This Bulletin
Defining the PCMH
Voices from the Field: Patti Wilson
Evaluation Update
Resource: Linkage Contact List
Meet Our Staff: Dan Clanon
Spotlight: Coach University Training
Next Steering Committee Meeting: 8/15/12
 
Meet Our Staff: Dan Clanon
 
Hello, I'm Dan Clanon, the IT specialist for HIV ACCESS PCMH Demonstration Project.  I helped implement LabTracker at many of the ACCESS sites over the last decade and continue to maintain and enhance the current system as we move to NextGen.  I'm an expert at all things LabTracker and am working to become expert with NextGen.  If you have data in LabTracker or CareWare and need a report on those data or an extract of data in Excel or Access, I can do it.  I hope to be able to say the same for NextGen in the coming months as I learn its data structure and reporting tools.
 
A few weeks ago I was privileged to sit in on a patient visit to observe the new NextGen workflow.   Although I was there to observe data entry, I was deeply moved by seeing in person how a talented and caring clinician helps a patient as part of a normal visit.  This isn't just a job for me.  It's helping all of you help the wonderful people in our community.  I look forward to continuing to support the quality care we provide to our clients.
Spotlight:  
Health TeamWorks Coach University Training

 

"Changing a complex system like a primary care practice is fraught with difficulties and challenges, leading to the common analogy of redesigning an airplane while it's flying. One of the most promising methods to support primary care transformation is a practice facilitation model that supports an ongoing, trusting relationship between an external facilitator and a primary care practice."
 - Agency for Health Research and Quality, December 2011

 

PCMH Project Director Erin Gael Chambers recently attended a week-long coach training with Health TeamWorks, a non-profit training organization in Colorado.  Health TeamWorks aims to build capacity nationally to redesign the healthcare delivery system and train PCMH practice facilitation coaches.  The hands-on approach of the training included working with clinics in the midst of the transformation process to create process maps, design PDSA (Plan Do Study Act) cycles for quality improvement, and  assist with teambuilding activities.  The training was also an excellent opportunity to network with health care professionals from around the United States who are tasked with helping their clinics move along the PCMH Implementation Continuum.  Erin is excited to take the learning from the "bootcamp"-style training and put it into practice with HIV ACCESS clinics in Alameda County.
 

For more information about Health TeamWorks coach training, please visit their website. 

Next Steering Committee Meeting August 15th

 

The next PCMH Demonstration Project Steering Committee meeting is scheduled for August 15th from 9:30 a.m.-12 p.m. at La Clinica de La Raza's Transit Village site (3451 East 12th Street, Oakland -- 3rd floor, Room 3C).

Want to know more about the PCMH Project?

 

For more information on our grant, view California HIV/AIDS Research Program's website.

 

For more information about the Alameda Health Consortium HIV ACCESS program, check out our webpage.

Contact Us:
 

Erin Gael Chambers, Project Director

[email protected]

 

Megan Crowley, Project Coordinator

[email protected]

 

Dan Clanon, IT Systems Specialist

[email protected]

 

Lois Bailey Lindsey, HIV Programs Director

[email protected]

 

Kathleen Clanon MD, Principal Investigator

[email protected]

 
 

View our videos on YouTube