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The Journey to the Patient-Centered Medical Home

July 25, 2012
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A family practice physician describes his journey to PCMH status

At the Healthcare Financial Management Association ANI annual conference last month in Las Vegas, I heard a presentation by Randall Gehle, D.O., about his involvement with helping his medical group make the transition to the patient-centered medical home (PCMH) model. He described the transition process, some of its challenges, and how it has had an impact on his family medicine practice.

Gehle belongs to CaroMont Medical Group, a mid-sized medical group that had 85 physicians when it started on its PCMH transition; it now has about 135 physicians, about half of whom are in primary care with 17 primary care sites; as well as an array of specialties. The group made the transition under the National Committee for Quality Assurance (NCQA) 2008 PCMH guidelines. Under those guidelines, the paper-based practices became recognized under Level 1 PCMH, the highest that can be achieved under paper; and the practices that had electronic integration became certified under Level 3 requirements, he said.

In Gehle’s view, the transition to a PCMH is a huge paradigm shift for many physicians. “For a lot of physicians, the practice of medicine centers around them, around their day, their needs and their requirements,” he said. He added that the transition to the PCMH model was also an adjustment for his office staff to be more focused on the needs or comfort of the patient.

One of the biggest changes in the medical group since making the PCMH transition has been the opportunity for physicians to take leadership roles in the group. Prior to that, physicians had little or no say in any process, Gehle said. Today, 12 physicians sit on the board, and every physician has the opportunity to participate through subcommittees. “There is a tremendous amount of physician input on the projects,” he said.

All meetings are held after office hours. “Physicians don’t take off work to attend meetings,” Gehle said, adding that there is a nominal monetary compensation for attending. He added that the meetings are well-attended.

Workflow changes resulting from the transition to a PCMH have been challenging, Gehle acknowledged. “The patient-centered medical home, meaningful use, all the P4P programs add things to a visit that we don’t normally see,” he said, adding that initially it was very burdensome. He noted that his practice has worked hard to shift “99 percent of that work to his staff, by getting people to work to the top of their pay grade,” so that most of the measures are met before the physician sees the patient.

Gehle said the practice has transferred an EMR (supplied by athenahealth), after being originally certified under another EMR. He says the group proceeded with a physician-by-physician rollout when it changed EMRs, eventually affecting all of the providers across its continuum. “It has gone well at this point. We’re getting our data and we are providing our quality,” he said. “All of our practices are PCMH or PPC [Physician Practice Connections, a program of the NCQA focused on medical specialists] practices now.”

Gehle said his practice accomplished the transition with minimal staffing changes. “We had to have a quality coordinator who managed the PCMH process. And she had an additional person on her staff. That was really the only FTEs that we added to organization as we went through this,” he said. “The key part of this is that it enables me to delegate a lot of the processes that I used to do to someone who can do it at their level.”

What has the transition meant to Gehle as a family practice physician? He said the ability to fill in the holes in the patient’s experience has been a huge asset of the PCMH process. “There are so many things that I couldn’t track, couldn’t follow up on that I can now, and I can make this patient’s experience continuous,” he said. “I know when my patients check into the hospital; we get automated emails that come to us when the patient checks in and what their diagnosis is.” Admissions, discharges, and consult notes are ion the patient’s EMR when the patient arrives in his office for his appointment, he said.

The result is that he is able to get things “right” more often, in terms of checking for medication interactions and tracking referrals through to completion. The ability to gather data has enabled him to contemplate pooling patients by diagnosis and condition, and seeing them in a more efficient setting. “We learned to do things we didn’t think we could do, and we are given feedback when we don’t,” he said. When he drops below a threshold for PCMH or meaningful use in any category, he gets a call from his quality coordinator, he said.

Gehle concluded that at the physician practice level, the transition to the PCMH has been a “paradigm shift for me from physician-centric care to patient-centric care.” Putting physicians at the table has been an improvement in the quality of life within his organization. “I feel like I’m part of the organization now, where before I didn’t,” he said.

He added: “Having that continuous, that whole circle of care for the patient has meant a lot to me as a practitioner. Most physicians don’t go into medicine to see a bunch of patients and make a bunch of money. Somewhere along the line they have a dedication to providing good care for their patients. And they are going to appreciate that part of this process.”