patient-centered medical home - peninsula...
TRANSCRIPT
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Patient-Centered Medical Home
The Foundation of Accountable Care
ACO M
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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
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The Medical Home is not a place.
• It’s a relationship.
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How We Did IT
• Policies and Procedures • “Playbook” • Detailing • Dashboard • Relieved practices from application
process
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NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
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NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
![Page 7: Patient-Centered Medical Home - Peninsula …peninsulaprofessionalcoders.com/PDF/PCMH_Peninsula...Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home](https://reader036.vdocuments.net/reader036/viewer/2022062415/5fdff1a2b4ceb8270529ca29/html5/thumbnails/7.jpg)
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
![Page 8: Patient-Centered Medical Home - Peninsula …peninsulaprofessionalcoders.com/PDF/PCMH_Peninsula...Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home](https://reader036.vdocuments.net/reader036/viewer/2022062415/5fdff1a2b4ceb8270529ca29/html5/thumbnails/8.jpg)
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
![Page 9: Patient-Centered Medical Home - Peninsula …peninsulaprofessionalcoders.com/PDF/PCMH_Peninsula...Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home](https://reader036.vdocuments.net/reader036/viewer/2022062415/5fdff1a2b4ceb8270529ca29/html5/thumbnails/9.jpg)
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
![Page 10: Patient-Centered Medical Home - Peninsula …peninsulaprofessionalcoders.com/PDF/PCMH_Peninsula...Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home](https://reader036.vdocuments.net/reader036/viewer/2022062415/5fdff1a2b4ceb8270529ca29/html5/thumbnails/10.jpg)
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
![Page 11: Patient-Centered Medical Home - Peninsula …peninsulaprofessionalcoders.com/PDF/PCMH_Peninsula...Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home](https://reader036.vdocuments.net/reader036/viewer/2022062415/5fdff1a2b4ceb8270529ca29/html5/thumbnails/11.jpg)
NCQA Standards Enhance Access / Continuity
Identify / Manage Patient Populations
Plan / Manage Care
Provide Self-Care Support / Community Resources
Track / Coordinate Care
Measure / Improve Performance
![Page 12: Patient-Centered Medical Home - Peninsula …peninsulaprofessionalcoders.com/PDF/PCMH_Peninsula...Patient-Centered Medical Home The Foundation of Accountable Care ACO Medical Home](https://reader036.vdocuments.net/reader036/viewer/2022062415/5fdff1a2b4ceb8270529ca29/html5/thumbnails/12.jpg)
Disease Management Forms
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mySmartPlan
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mySmartPlan
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The Dashboard
• Define populations • Identify Care Gaps • Stratify Risks • Manage Care • Measure Outcomes • Monitor Practice
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PCMH Dashboard
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Service Line and Practice Indicators
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Practice Tools / Indicators
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PCMH Tools / Indicators
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PCMH Tools / Indicators
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PCMH Tools / Indicators
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PCMH Tools / Indicators
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PCMH Tools / Indicators
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PCMH Tools / Indicators
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PCMH Tools / Indicators
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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