The Problem

Frequently, primary clinicians instructs patients to follow up a visit with a specialist or a specific course of treatment. For many reasons, these instructions often do not get seen to fruition; whether the patients simply don't follow through, or there is a communication gap between the patient and specialist, or the patient doesn't know how to navigate the insurance system, the chain is broken and the medical care is incomplete. In a traditional primary care model, the original clinician may never learn of this gap in care.

The Solution

Enter the Patient-Centered Medical Home (PCMH) concept. The PCMH model offers team-based, comprehensive care that accommodates each individual patient's needs and preferences. The “medical home” is the patient's primary care facility. This can be a pediatrician, internist, general practitioner, internal medicine pediatrician or family practitioner. It is the responsibility of the patient's primary clinician within the medical home to provide and coordinate the physical and mental health care of the patient. This care may be carried out by the clinician, by other practitioners within the medical home setting, or by specialists within the community. Regardless of who is performing the treatment, it is the responsibility of the primary clinician to coordinate and follow up on all areas of the patient's health care needs including wellness visits, acute care, chronic illness, and end-of-life concerns. Whether it's an appointment at the patient's medical home or a stay in the hospital, the follow-up for the patient will always be appropriately monitored through the PCMH model.

The Benefits

Becoming a PCMH offers many benefits to you as a health care provider. Once the systems are in place to qualify your practice as a patient-centered medical home, you will be able to offer your patients the most comprehensive and well-coordinated care available. There are also financial benefits to becoming a certified PCMH including a 10% uplift in your E&M services.

The Process

The Center for Healthcare Research & Transformation (CHRT) working with Blue Cross Blue Shield of Michigan’s (BCBSM’s) Physician Group Incentive Program (PGIP) determined the attributes that correlate with progress towards becoming a PCMH. BCBSM lists  12  “Domains of Function” that are key in becoming a PCMH:

  • Patient-Provider Partnership
  • Patient Registry
  • Performance Reporting
  • Individual Care Management
  • Extended Access
  • Test Results Tracking & Follow-Up
  • Preventive Services
  • Linkage To Community Services
  • Self-Management Support
  • Patient Web Portal
  • Coordination of Care
  • Specialist Referral Process

Under each of these Domains of Function, there are required capabilities that must be in place and in use routinely.

The Help from NPO

NPO's objective is to provide the tools and education necessary to help our eligible members achieve PCMH certification.  The NPO Clinical Team is available to help you meet the requirements needed to satisfy the capabilities within the Domains of Function. This will position your practice for PCMH designation and make your practice eligible for the incentives for doing what you already strive to do: offer quality, comprehensive medical care to all your patients. An added bonus is that documentation of completion of these webinars will assist in satisfying the capabilities.

NPO nominates practices for PCMH designation based on the systems they have in place as determined by the PCMH guidelines. Following site visits by NPO staff and BCBS representatives, designation is announced by BCBSM in July. Those practices will then receive a 10% uplift in their E&M services. It is important to begin satisfying the capabilities now; NPO will nominate additional practices for PCMH certification in November/December of this year.