State Created Standards for PCMH

Some states have created their own standards for patient-centered primary care (or medical) homes to innovate. For example:

Case Study: Colorado Accountable Care Collaborative

Background

The Colorado Department of Health Care Policy and Financing (HCPF), the state Medicaid agency, began implementing the Colorado ACC in 2011 to “move from a system that rewards high volumes of services to one that rewards high quality of services and better health outcomes.” [i] The ACC is using the PCMH model of comprehensive, coordinated, team-based, and client-centered care as a building block.

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Under the model, primary care medical providers (PCMP), including physicians, nurse practitioners, and physician assistants, contract with the regional care collaborative organization (RCCO) in their practice area to serve as the medical home for assigned enrollees. PCMPs are responsible for providing health care services and assessing non-medical needs such as housing, behavioral health services, and social services. The PCMP and/or the RCCO help clients assess these services.

On top of standard fee-for-service payments, PCMPs receive a per-member/per-month payment (PMPM). They are also eligible for incentive payments for meeting key performance measures. An additional PMPM payment (called Enhanced Primary Care Provider Payment) is made if the provider can document doing at least five of the following:[ii]

  1. Provide appointments at least once a month outside of regular business hours
  2. Provide clinical advice by telephone or secure messaging during and after hours
  3. Use data to identify patients who may need extra services and support
  4. Provide onsite access to behavioral health providers
  5. Administer a behavioral health screening (including substance use) and/or developmental screening for children and has processes to address positive screens
  6. Maintain a list of patients receiving care coordination
  7. Track referrals to specialty care providers and provides the clinical reason for the referral along with pertinent clinical information
  8. Accept new Medicaid clients for the majority of the year
  9. Collaborate with patient/family to develop and update an individual care plan


Case Study: Northside Child Health Center, Montrose, CO

The Northside Child Health Center is a school-based health center located in Montrose, a small rural community on the western slope of Colorado. Northside opened in 2007 and serves as the pediatric safety net clinic for the community. The Montrose School District operates the clinic and employs the SBHC behavioral health provider, family outreach coordinator, and receptionist. They contract with Pediatric Associates to provide the medical services of a nurse practitioner. Northside also partners with the Montrose Community Dental Clinic to provide a dental hygienist part time onsite.

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For Northside, PCMP recognition through the Colorado ACC has the potential to increase their revenues and patient base, but it also allows them to be part of a larger movement to improve the health care delivery system. “It’s important that SBHCs be recognized as high quality clinics by holding themselves accountable to the same PCMH standards as other pediatric practices,” said Jennifer Suchon, MSN, PNP-BC, FNP-BC, Medical Provider and Clinic Director of the Northside Child Health Center (personal communication, March 8, 2016).

The Approach Taken

It took approximately 4-5 months to enroll with the local RCCO, Rocky Mountain Health Plans, once it was determined who would sign the contract (see Challenges below). They currently receive $3/month for each patient who selects or is assigned to the SBHC, in addition to fee-for-service reimbursement. They have not yet applied for Enhanced Primary Care Provider Payments but plan to do so in the near future. This will require that they undergo a practice assessment to document that they meet at least five of the nine criteria before receiving this additional payment.

Challenges

The biggest challenge for Northside was determining the terms of the RCCO contract. The RCCOs are accustomed to contracting with medical entities, which the Montrose School District is not. However, because the Montrose School District operates the SBHC and already had a contract with Rocky Mountain Health Plan, they decided that the Montrose School District would be the contractor. The contract does specify that the medical records are owned by its contracted provider, Pediatric Associates.

Impact

The overall impact has been positive. As predicted, they are generating increased revenues. Ms. Suchon also reports that the process has “nudged” them forward in terms of quality improvement. Their RCCO, which is also the Medicaid Managed Care Organization, requires regular Healthcare Effectiveness Data and Information Set (HEDIS) chart audits.

Being part of the RCCO has increased their visibility and credibility in the community. Ms. Suchon believes their participation will contribute to the long term sustainability of the SBHC as funders and that others will recognize Northside as a sound investment.


References

[i] The Accountable Care Collaborative. (2016). Colorado Department of Health Care Policy and Financing. Retrieved March 8, 2016, from https://www.colorado.gov/pacific/hcpf/accountable-care-collaborative-provider-information

[ii] Accountable Care Collaborative (ACC) Incentive Payments: Enhanced Primary Care Medical Provider definitions page. (2016). Retrieved March 8, 2016, from https://www.colorado.gov/pacific/hcpf/accountable-care-collaborative-acc-incentive-payments

Alternative PCMH Models
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