Many primary care practices wish to become patient-centered medical homes, but the transformation process can be daunting. Here, three experts offer some professional advice.
By Joan D. Johnston, R.N.; Jaime Vallejos, M.D.; and Jeanne Cohen, R.N.
As soon as we walked through the doors of the urban community health center that we were going to help achieve patient-centered medical home recognition, we saw a practice that was passionate about obtaining the recognition, but overwhelmed to the point of paralysis. We are a team of certified patient-centered medical home content experts from the University of Massachusetts Medical School
. In our work with health care organizations and practices seeking recognition from the National Committee for Quality Assurance
(NCQA), we are always reminded that achieving this designation requires thoughtful planning, strategy and commitment. Through hard work and with our support and guidance, the community health center achieved Level 2 recognition from NCQA. And they learned it doesn’t have to start out so difficult.
Before starting the journey to medical home recognition, research the standards and ensure your staff members review them as well. Your staff will play a critical role in the recognition process. If the entire practice does not understand the standards, your team may waste time gathering unnecessary data or misunderstand what information is required. A small family practice we worked with didn’t take the steps required before completing a records review workbook – a mistake that could have led to a rejection had it not been caught. We urge practices to start by checking out these free online resource
s with their team.
The path to recognition is a marathon, not a sprint, and your staff should be prepared for a hefty time commitment. The process can take as long as two years from start to finish. As you identify the standards and materials required by NCQA, new questions and solutions may emerge. We know practices that claimed to have standards for patient communication, only to find out they were not accurately recorded or regularly updated. National recognition requires your processes be in place for three months at the time of submission, so your team may need to adapt its approach as it proceeds.
Also keep in mind that the process will demand resources, such as personnel, technology and monetary investments. Non-billable staff hours may be required to accomplish recognition. In fact, one urban community health center dedicated 50 percent of one nurse’s time to overseeing and coordinating its submission. Technology investments could include an electronic medical record and new or updated software. Additional funds may be used for overlooked priorities, such as staff retreats and office supplies.
To tackle the standards in an organized manner, high-level decision-makers need to take a leadership role in the national recognition process. The physician-owner of a suburban practice empowered her staff by supporting their efforts and designating time in their work day to focus on the recognition process. She also served as an ambassador to encourage practice-wide buy-in to achieve national recognition.
As part of this, decision-makers should designate a leader who can assemble an interdisciplinary team. The leader should pick team members who have the confidence to navigate all levels of the organization and are comfortable making requests of both front-line staff and providers. In one rural pediatric practice we supported, the brand new practice manager was selected to lead the charge. Why? Because the manager could simultaneously orient herself to the practice and check off a list of information required to achieve recognition.
In addition, leaders should designate a person who has strong technology skills – particularly in Word, Excel and electronic medical records – to coordinate the submission of paperwork to NCQA. One of the best submissions we’ve ever seen was completed by an independent adult internal medicine practice. It was consistent and showed attention to detail down to the uniform sizes of headings and columns. The presentation helped the practice earn level 3 recognition – the highest level that NCQA grants.
The practice must also improve to reach national recognition. Perform a gap analysis to compare your practice in its current state against recognition requirements. We were impressed by how one inner-city health center completed this step. They assigned each standard to a staff member unfamiliar with its impact on the practice, a move that resulted in an objective assessment of the current practice state. Their initial gap analysis became a living document the team updated as they moved forward in the recognition process.
In addition, conduct a preliminary chart audit to monitor the practice's care delivery processes. Use what you learn to craft detailed improvement strategies that can be shared with staff at all levels of the organization. In a mid-sized urban pediatric health center, the chart audit revealed one provider routinely failed to record and communicate care delivery at the level required. The provider was retrained – as well as moved closer to a printer – and monitored to ensure improvement.
Finally, schedule a full-day team review of your recognition documentation about 45 to 60 days before submission. Practices that take this extra step often have better outcomes because they catch inconsistencies or minor errors. A review conducted by the team from a large city hospital’s pediatric clinic revealed a quality worksheet with missing information. Had the clinic not caught their mistake, it could have meant the difference between remaining unrecognized and what they actually achieved: Level 3.
These steps take your practice leaps forward in reaching national standards, but you may need expert help to achieve the status you want. Though the process is labor-intensive, it can be an exercise in team-building – of which the ultimate beneficiaries are our patients.
Joan D. Johnston, RN, CIH, CPE, PCMH CCE, is a manager of performance improvement within the University of Massachusetts Medical School’s Commonwealth Medicine division. She is currently working on the implementation of the Massachusetts Primary Care Payment Reform training and education curriculum.
Jaime Vallejos, MD, MPH, PCMH CCE, is program development manager and primary care transformation specialist within the University of Massachusetts Medical School’s Commonwealth Medicine division. He assisted in the implementation of the Massachusetts Patient Centered Medical Home Initiative (MA-PCMHI), and is now helping with the design and execution of training for participants in Massachusetts primary care payment reform.
Jeanne Cohen, RN, MS, PCMH CCE, was the clinical care management lead within the University of Massachusetts Medical School’s Commonwealth Medicine division for four years. She recently joined the team at Southcoast Accountable Care Organization to serve as director of care management.