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(Adapted from The Patient-Centered Medical Home and Your P4P Goals: Your Guide for Getting Engaged and Generating Results Now, by Frank Irving, originally published in March 2011 and sponsored by Intel and NextGen Healthcare.)
Systemizing comprehensive care In February 2009, James Holly, MD, co-founder and CEO of Southeast Texas Medical Associates (SETMA), attended a workshop introducing the concept of the medical home. He left the meeting unclear about what being a medical home meant, but determined to learn.
To this end, SETMA, a multi-specialty clinic, performed a comprehensive analysis of its operations. While SETMA had focused on disease management during its implementation of the NextGen Ambulatory EHR from NextGen Healthcare, its future plans to improve patient-centered care - and apply for NCQA PCMH recognition - called for a new approach. Dr. Holly understood that it would require scrutiny of patient-care data in order to change provider and patient behavior; change practice procedures and processes; and improve patient health through a focus on preventive care.
By seeking PCMH Level 3 recognition, the highest level, SETMA saw an opportunity to:
- incorporate national quality-of-care standards into the EHR and workflow;
- use tools at the point of service to enable evidence-based medical care;
- measure provider performance in real time; and
- examine patterns of care and outcomes using statistical methodologies.
SETMA achieved Level 3 recognition in July 2010. Reflecting on the accomplishment, Dr. Holly comments, “To reach PCMH recognition, a practice must provide patient communication with a personal physician who accepts full, primary responsibility for each patient’s care. It includes efforts such as answering health-related inquires at any time; providing telephone access with same-day response and facilitating email contact through secure Web portals.
Continuity of care in the electronic age also involves making each patient’s record available at every point of care - clinic, hospital, emergency department, nursing home, healthcare provider’s home and others.”
A health information exchange launched by SETMA provides accessibility to the patient chart by hospitals, emergency rooms, specialists and primary care providers. SETMA’s Web portal lets patients maintain and periodically review their own PHR. In addition, a written and personalized “plan of care” and “treatment plan” are provided to the patient at each clinic visit. A “transition of care” analysis is done each time the patient moves from one level of care, such as from hospital in-patient care to ambulatory care. This analysis, based on national standards of care for transition, provides the patient written, reconciled medication lists; detailed follow-up instructions; and personalized self-care information.
“It places patients at the center of their healthcare decision-making processes, which encapsulates the PCMH ideal,” says Dr. Holly.
SETMA’s self-assessment and journey to PCMH recognition meant moving from meeting national standards solely on a patient-by-patient basis to measuring treatment across broad patient populations. In doing so, SETMA laid the cornerstone for the program it now calls the SETMA Model of Care, encompassing the areas of data-tracking, auditing, analysis, reporting and improvement.
Dr. Holly concludes, “SETMA continues using innovative technologies and processes to more completely transform SETMA’s Model of Care into a robust PCMH.”
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