A Path to Medical Home Status: Insights from Ryan White Grantees
What does it take to become a primary care medical home (PCMH)—a designation that offers the potential for added reimbursement for delivering care in a more effective, coordinated, manner? How long does it take? What do you have to do? And once you have it, what does PCMH status provide?
Those questions and more are certainly on the minds of many Ryan White agencies. This feature article offers some answers in the form of what a handful of Ryan White entities did in order to achieve PCMH recognition. The path these trailblazers took is certainly easier today given new technical assistance available to Ryan White Grantees under HRSA's HIV/AIDS Bureau via the HIV Medical Homes Resource Center (see sidebar).
A Tale of Two Grantees
Long before the Center opened its doors, Ryan White agencies around the country started work on medical home recognition. In early 2012, two grantees—one in Wisconsin and one in Florida—shared their stories with HRSA about how they achieved Level 3 medical home status from National Committee on Quality Assurance (NCQA)—the highest level of PCMH recognition. The AIDS Resource Center of Wisconsin (ARCW) earned their status in July 2010. The University of Florida Center for HIV/AIDS Research, Education, and Service (UF CARES) achieved recognition in early 2012. Below are some of their observations.
First Step: Assess Your Readiness
UFCARES began its investigation of the PCMH process by meeting with a fellow primary care physician who had recently obtained Level 1 status. He recommended purchase and use of the NCQA 2008 PPC-PCMH Survey Tool as a way to assess the agency's readiness for the PCMH recognition process. PCMH readiness involves many items that cannot be done the night before applying. The clinic or agency must already have a fairly robust electronic health record, an existing patient satisfaction survey, and a system of capturing quality metrics and designing interventions based on their performance on those metrics.
Going Through the Process
Our two Ryan White grantees had vastly different PCMH experiences in terms of time frames, processes, and starting points. Competing priorities and available staff were among the determining factors. UFCARES was ready to submit within 10 months, but some delays stretched this out to a year (see below).
In contrast, ARCW took three months, according to John Fangman MD, ARCW Medical Director. ARCW was fortunate to have a full-time Director of Quality, Thomas Novak, who joined the Agency in 2009, well before they began the certification process. Tom initiated a quality management planning process that included review of both HIV-specific and primary care quality measures. Before this plan was finalized, ARCW reviewed the NCQA certification criteria in an effort to streamline NCQA PCMH certification. The PCMH application focuses heavily on capturing quality metrics and designing quality improvement initiatives. ARCW's quality management team includes providers, nurses and administrators whose efforts synergized effectively with the PCMH certification efforts fairly seamlessly. As part of its quality management infrastructure, ARCW was already capturing quality metrics and had begun to use our data to initiate several quality improvement initiatives. Although the PCMC application took around three months to complete, the quality plan required a substantially greater investment of time and resources to complete. In addition to an established quality plan, ARCW was already sharing de-identified quality data with regulators and a Milwaukee/Chicago Regional Quality Collaborative. The PCMH application emphasizes the importance of sharing quality data for benchmarking and goal setting.
The PCMH process is designed to take just months to complete. However, delays are probably inevitable as agencies struggle to find the time to meet, compile information, and make needed adjustments in operations in order to comply with PCMH requirements. ARCW's submission was delayed when they switched there Electronic Health Record (EHR) from LabTracker to EPIC. Although this lead to a delay in certification, the switch allowed ARCW to document improved EHR functionality, such as e-Prescribing, that took their submission from Level 2 to Level 3.
UFCARES faced, and overcame, a number of challenges (see UFCARES PCMH Steps). One of the biggest was to be sure they they were accurately interpreting what each of the PCMH measures meant, and what needed to be provided in response. According to Melissa Scites, Executive Director of UF CARES, "some TA and data source examples were provided, but it was not entirely intuitive" as to what they all entailed.
Outcomes to Date
What did PCMH designation do for ARCW and UFCARES? It's too early to tell. ARCW is waiting to hear about a Wisconsin State Medicaid program plan amendment that was submitted to HHS, which—if approved—would fund an HIV Medical Home Initiative UFCARES is working with their billing department to identify additional reimbursements available through specific insurance providers and is still waiting to confirm actual cost savings. Based on initial inquiries, there is at least a 2% anticipated increase in the reimbursement percentage for some private insurers. Scites of UFCARES also reports: "Other than cost savings, I think the biggest impact on our program has been a uniting of all of our team members and engaging them in the process of ensuring we are providing the highest quality of patient care to our patients. Everyone… is very proud of our PCMH accomplishment."
One other advantage is that NCQA cross-walked the PCMH requirements with the ARRA/HITECH Meaningful Use requirements. Therefore, PCMH accreditation will most likely make it easier for those wishing to apply for EHR incentive payments, assuming those clinics and agencies meet the other eligibility requirements. The PCMH certification process also lead ARCW to expand quality improvement initiatives beyond traditional HIV measures into areas such as blood pressure management and improved care of dyslipidemia.
UFCARES PCMH Steps
Below is a synopsis of the year-long process that Ryan White grantee UFCARES went through in order to achieve PCMH recognition.
Month 1: Assess Readiness. Implement the NCQA readiness survey tool, with review of materials, standards and elements.
Months 2-4: Plan. Key members of the existing Clinical Effectiveness Group (part of their CQI effort) were assembled and increased their normal once a month meeting schedule to twice monthly to focus on the PCMH application. The team went through each standard and element, assigning specific tasks to members, such as developing Standard Operating Procedures to document for example, how they met the standard of access to care and patient follow-up and communication.
Months 5-6: Resolve Key Challenges. UFCARES ran into some organizational challenges related to data reporting for some PCMH elements that caused a several month-long delay until key stakeholders could resolve the matter. Other UFCARES clinics were also applying for recognition, so an organizational-wide committee was created to assist with utilizing system resources.
Months 7-9: Detailed Review. UFCARES conducted a detailed review of each PCMH element and uploaded hundreds of pages of documentation and screen shots to demonstrate performance. This required a hard look at current processes and the need for a few system changes and improvements specifically related to patient tracking and follow-up.
Months 10-12: Finalize, Submission, and Approval. UFCARES was ready to submit at month 10 but first had to address additional challenges in finalizing organizational contracts and language agreements. Submission was in December of 2011 and notification of Level 3 recognition came in February 2012.
PCMH Around the Nation
PCMH work is underway in various states and communities—from changes in reimbursement policies under Medicaid to agency work to achieve PCMH recognition. Below are two examples from California:
- In 2010, the California HIV/AIDS Research Program awarded $6.3 million to five California health care provider organizations under their PCMH demonstration project to explore the effectiveness of PCMH for persons with HIV/AIDS. The research is examining cost, quality, patient satisfaction, and patient self-management.
- Also in 2010, the Los Angeles County Part A Ryan White Planning Council and grantee decided to migrate from a case management model to medical home model and completed a multi-stage assessment in 2010. They were motivated to do so in order to improve service delivery, to be responsive to the greater focus on medical care under Ryan White, and to keep abreast of national changes.