Patient Centered Medical Homes

1. Patient Centered Medical Homes Marcia Hamilton SW722 Fall, 2014

2. 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

3. 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;

4. 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.

5. (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

6. 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 low-income 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.

7. 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.

8. 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.

9. Where the rubber meets the road... What are the regulations regarding PCMH in the ACA?

10. 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.