Frequently Asked Questions

February 16, 2015 PCMH0

What Is a Patient Centered Medical Home?

A Patient Centered Medical Home (PCMH) is a team-based model of providing care, designed to support providers in improving and maintaining the health of their patients. The PCMH model highlights the unique skills of individuals in the care team and the importance of the patient’s role in their own health. PCMH recognizes that providing real and complete healthcare requires a team of caring professionals centered around an informed patient.

Are all patients part of our Patient Centered Medical Home?

YES, the National Committee for Quality Assurance requires that medical practices meet certain criteria to become recognized as a PCMH. However, only some payers recognize this participation and pay health systems for it. These payers may have guidelines that differ from NCQA’s PCMH application. For example, some payers have special criteria for patients with a certain conditions or risks.

I have a patient with Diabetes in a PCMH payer program who sees an endocrinologist or cardiologist– should this patient still be part of our PCMH program?

YES, all of your patients will be part of PCMH once the practice has been recognized. However, NCQA and the payer require the primary care provider to review records from the endocrinologists, cardiologists & other specialists, hospital, labs, and imaging data.

How can transforming to a PCMH work for you?

As of June 2013, 5730 practices have received NCQA’s PCMH recognition. ERHS is currently in the process of achieving recognition.

As a recognized provider, PCMH goals include improved medication adherence, decreased ER and hospital utilization, improved self management education, improved patient satisfaction and an overall improvement in clinical outcomes.

As a result, a PCMH will also encourage patients to become more actively involved in their health while allowing everyone on the care team to work to the highest level of their license. ”

  • Recognition requires transformation, increased emphasis is placed on:
  • Care teams & shared responsibilities
  • Huddles
  • Improved patient engagement
  • Improved adherence to MU
  • Better results on patient surveys
  • Evidence based medicine guidelines incorporated into workflows
  • Improved care coordination

Transforming– What’s next?

Over the next several months, your practice will continue to generate reports, monitor progress on quality measures, transform workflow to improve and streamline patient care and disseminate this information to all of the primary care practices. Please feel free to provide input to help us make these necessary changes in order to meet NCQA and payer criteria.

Our goal is to apply for recognition in the December/January timeframe– we hope to achieve a Level III (the highest level of recognition given by NCQA).

“Nothing worth having comes easy”

 It’s not only what we do, but also what we do not do, for which we are accountable.” -Unknown

“You must be the change you wish to see in the world.”

~Mahatma Gandhi

What Changes will my patients notice?

From a patient’s view, the transformation will have a big impact from wait times to more coordinated care (getting patients records from outside facilities, labs and imaging results) to proactively following up with patients who have been to the hospital or seen a specialist. There will also be a greater focus on preventative medicine and what the patient can do to have an impact on their health. Things like medication adherence, self management support (diet, exercise, self monitoring blood pressure and blood glucose) and motivational interviewing- the patient will feel they have empowerment in their health care vs. the traditional approach to care where the provider dictates what the patient needs to do. Patients will also have access to after hours care through a call center and Express Care’s two locations. They may also be connected to community resources that can help them receive financial support, counseling, education, and other resources they may need.

Patients won’t have to wait in the office while their provider asks office staff to find records from their recent hospital visit or visit to the specialist because PCMH workflows requires these tasks to be proactively done before the patient is seen.

Overall, PCMH patients typically experience a higher level of care through the focus on: the care teams, proactive preventative care, lowering costs, improving patient outcomes and patient satisfaction.

What to expect during transformation…


As your practice continues to transform into a PCMH, you will continue to see changes occurring throughout your practices. In order to achieve the highest level of recognition given by NCQA, a variety of training’s must be completed by all members of the care team in order to provide the best possible care for your patients. In the next few weeks you and members of the care team should expect to see training’s focused on:

  • How to best coordinate care for individual patients by tracking and following up on test and referral results
  • How to support patients and families in self-management through patient coaching and motivational interviewing
  • Population management– how to proactively address needs of certain patient populations and manage their specific health need
  • How to communicate effectively with patients, particularly vulnerable populations such as certain health conditions, age, payer type, etc.

These training’s will occur in a variety of settings. Some will be presented in a 20 to 30 minute informational video, on-site training session, and power points.

Care Plans and Self Management Goals

A crucial element of becoming a successful Patient Centered Medical Home is developing care plans. Care plans need to filled out and discussed with patients who have diabetes, hypertension, obesity, depression, and patients with a combination of these diseases. These care plans will be created by your IT team with regard to your suggestions/needs. A care plan needs to be created and/or updated and sent home with the patient at each visit that the patient is seen for one of the previously mentioned conditions. The care plans will include patient/family education, treatment goals and access to self-management tools. The physicians and nurses will be responsible for going over each element of the care plan with the patient. Physicians or nurses will also be expected to ask patients questions specific to their medication adherence and emotional well-being. An example of the care plans will be made available soon.

In order for your practice to make this transformation as smooth as possible for you and your care team, please feel free to provide feedback at any time.