Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home Medical Home Medical Home Medical Home Medical Home Medical Home
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Patient-Centered Medical Home
The Foundation of Accountable Care
ACO M
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al H
ome
Med
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Hom
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Med
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Med
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PCMH Principles Personal physician Physician-directed medical care team Whole person orientation Coordinated/integrated care Quality and safety Enhanced access Payment that reflects the value of all that above
The Medical Home is not a place.
• It’s a relationship.
How We Did IT
• Policies and Procedures • “Playbook” • Detailing • Dashboard • Relieved practices from application
process
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
Disease Management Forms
mySmartPlan
mySmartPlan
The Dashboard
• Define populations • Identify Care Gaps • Stratify Risks • Manage Care • Measure Outcomes • Monitor Practice
PCMH Dashboard
Service Line and Practice Indicators
Practice Tools / Indicators
PCMH Tools / Indicators
PCMH Tools / Indicators
PCMH Tools / Indicators
PCMH Tools / Indicators
PCMH Tools / Indicators
PCMH Tools / Indicators
PCMH Tools / Indicators
Results
• 27 / 30 primary care practices NCQA Level III recognition in less than a year
• Last 3 ready to go; preparing applications now
• Has seemed to impress payors as we have discussed accountable care
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