Did you know that we are taking part in an innovative program to improve primary care for our patients? Griffin Faculty Practice is working to become an “Advanced Primary Care Practice” also known as a “Patient Centered Medical Home”. These programs are recognized by the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA).
What is an Advanced Primary Care Practice/Patient Centered Medical Home?
The Advanced Primary Care Practice / Patient Centered Medical Home is a model of primary care that seeks to improve primary care in five specific areas/attributes:
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Comprehensive Care
The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities.
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Patient-Centered
The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.
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Coordinated Care
The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.
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Accessible Services
The primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients’ preferences regarding access.
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Quality and Safety
The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.
When will the transformation be complete?
The process of being recognized by NCQA as an Advanced Primary Care Practice/Patient Centered Medical Home is a lengthy one. It involves changes in policies, practices and systems. We have already begun the process and have key infrastructure already in place, including an Electronic Health Record (EHR) System in place which includes a patient portal with 24/7 access for our patients. Other changes are in progress.