Obtain Patient-Centered Medical Home (PCMH) Recognition the "HI"-Way.

Checkpoint 1: Develop your practice team and identifying gaps

Developing a practice team is essential to the transformation process.  HI will assist your practice in evaluating your current practices to determine which of the NCQA core and selective criteria you currently meet.  We will then develop job descriptions that include NCQA essential accountabilities, design an agenda for weekly huddles, update patient forms to include essential elements per the NCQA requirements, and outlining communication strategies to yield a successful transformation.  Products delivered at the end of Checkpoint 1 include alignment of key personnel with job accountabilities, and functions, written policies with their associated forms.
 

Checkpoint 2: Manage your patient population

One of the greatest barriers to revenue generation is patient no-show rates.  The NCQA offers a patient centered approach, whereby you can assist your patients in understanding that you have the capacity and capability to meet their health care needs.   This approach incudes addressing no show rates, decreasing patient use of urgent care/emergency rooms for illness that can be managed in primary care, reducing hospital admissions, and improving patient outcomes through the effective use of patient care plans.  During this phase, clients must gain an appreciation for their electronic health record capabilities, and start using their electronic health record to its maximum capacity to manage and treat patients effectively.  Final deliverables for this phase includes NCQA specific policies, staff efficiencies, strengthened office procedures, and a streamlined work environment. 
 

Checkpoint 3:  Initiate Quality Improvement projects

Continual quality improvement is essential to effective practice.   During this phase, the staff will execute quality improvement projects that are aligned with your patient population.  This will include developing surveys and identifying areas for improvement.  Final deliverables for this phase includes designing QI projects, determining baseline measures, conductive projects, and demonstrating improvement.
 

Checkpoint 4:  Put new evidence into practice

After your practice has generating the forms, policies, and procedures necessary to transform, the team will then maximize use of the electronic health record by incorporating order sets, office protocols, standardized forms, and patient care plans to deliver focused care.  During this phase, the team will identify key prevalent conditions that require active management in the patient population and develop strategies to address these in the primary care setting.  Final deliverables of this phase includes incorporating evidence into practice and improving patient outcomes. 
 

Checkpoint 5:  Manage care delivery

Care coordination is a key component of the patient centered medical home, and entails actively managing ordered labs, referrals, and images from initial order to patient completion.  This process combines a coordinated effort between the clinician, medical assistant and care coordinator.  During this phase, the practice will be developing relationships with local hospitals and other care facilities, as well as strengthening relationship with specialty providers.  As the transformation process fully takes shape, your patients will experience increased access to care, improved patient outcomes, and increased patient/clinician satisfaction.   You will maximize the quality of the patient encounter through streamlined practices, and greater access to current resources.
 

Checkpoint 6:  Perform as a PCMH

During this phase, you will fully realize the value of transformation.   The practice will enjoy the benefits of using their electronic health record to its fullest capacity, have a set of tailored policies that serve as both a reference and a guide for care delivery, and experience stronger patient-clinician relationships.      
 

Checkpoint 7:  Re-certify your practice as a PMCH

After receipt of the initial recognition, practices must continue to comply with NCQA recognition standards to maintain the PCMH designation.  We continue to assist our clients during this process and develop strategies to maintain NCQA PCMH standards.