Download Patient Centered Medical Homes

Patient Centered Medical Homes
Marcia Hamilton
SW722
Fall, 2014
History
• Concept emerged in 1960s for chronically ill
pediatric patients
• It then spread to family practices and other
physicians
• The ACA recognizes seven generally accepted
joint principles that define a PCMH
Text from the ACA
SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO
SUPPORT THE PATIENT-CENTERED MEDICAL HOME
...support patient-centered medical homes, defined as a mode
of care that includes—
(A) personal physicians;
(B) whole person orientation;
(C) coordinated and integrated care;
(D) safe and high-quality care through evidence-informed
medicine, appropriate use of health information technology,
and continuous
quality improvements;
(E) expanded access to care; and
(F) payment that recognizes added value from additional
components of patient-centered care;
Paraphrased from the ACA
(a) IN GENERAL.—The Secretary of Health and Human
Services shall establish a program to provide grants to or
enter into contracts with eligible entities to establish
community-based interdisciplinary, interprofessional
teams to support primary care practices, including
obstetrics and gynecology practices, within the hospital
service areas served by the eligible entities. Grants or
contracts shall be used to—
(1) establish health teams to provide support services to
primary care providers; and
(2) provide capitated payments to primary care
providers as determined by the Secretary
(3) support patient centered medical homes.
(b) ELIGIBLE ENTITIES To be eligible to receive a (PCMH) grant or contract an
entity shall:
(1)(A) be a State or State-designated entity; or (B) be an Indian tribe or tribal
organization, as defined in section of the Indian Health Care Improvement Act;
(2) submit a plan for achieving long-term financial sustainability within 3 years;
(3) submit a plan for incorporating prevention initiatives and patient education
and care management resources into the delivery of health care that is
integrated with community-based prevention and treatment resources, where
available;
(4) ensure that the health team established by the entity includes an
interdisciplinary, interprofessional team of health care providers, as determined
by the Secretary; such team may include medical specialists, nurses,
pharmacists, nutritionists, dieticians, social workers, behavioral and mental
health providers (including substance use disorder prevention and treatment
providers), doctors of chiropractic, licensed complementary and alternative
medicine practitioners, and physicians’ assistants;
(5) agree to provide services to eligible individuals with chronic conditions, as
described in section 1050
SEC. 340H. COMMUNITY-BASED COLLABORATIVE CARE
NETWORK PROGRAM.
IN GENERAL.—The Secretary may award grants to eligible
entities to support community-based collaborative care
networks that meet the requirements below
(1) DESCRIPTION.—A community-based collaborative care
network shall be a consortium of health care providers with a
joint governance structure (including providers within a single
entity) that provides comprehensive coordinated and integrated
health care services (as defined by the Secretary) for lowincome populations.
(2) REQUIRED INCLUSION.—A network shall include the
following providers (unless such provider does not exist within
the community, declines or refuses to participate, or places
unreasonable conditions on their participation): a hospital and
all Federally qualified health centers located in the community.
Grant funds may be used for the following activities:
(A) Assist low-income individuals to—
(i) access and appropriately use health services;
(ii) enroll in health coverage programs; and
(iii) obtain a regular primary care provider or a medical
home.
(B) Provide case management and care management.
(C) Perform health outreach using neighborhood health workers
or through other means.
(D) Provide transportation.
(E) Expand capacity, including through telehealth, after-hours
services or urgent care.
(F) Provide direct patient care services.
Hawaii’s Healthcare Innovation Plan
PRIMARY CARE PRACTICE REDESIGN
Ensuring that at least 80 percent of Hawai‘i’s residents are enrolled
in a Patient-Centered Medical Home (PCMH) by 2017 and
integrating behavioral healthcare into the primary care setting
This is voluntary for providers, with the incentive being that all
plans and payers have already agreed to reimburse providers who
meet PCMH Level 1 criteria at a higher level than those who do not.
Those who meet the criteria will get a higher fee-for-service rate
and a PCMH payment.
CARE COORDINATION
Implementing programs for high-risk/high-need populations,
including establishing Medicaid Medical Homes and Community
Care Networks for high-risk Medicaid and commercial beneficiaries
and initiating super-utilizer pilot programs.
Where
the rubber meets the road...
What are the regulations regarding
PCMH in the ACA?
Two steps to federal regulations
• 1. Publish proposed and final rules in the
Federal Register. All analyses must be done
and all comments must be addressed.
• 2. Update the Code of Federal Regulations to
reflect the new rule.