By Kathy Kunath, RN
Clinical Health Coach
Training and Partner Relations
The Patient-Centered Medical Home (PCMH) is a care delivery model where patient treatment is coordinated through primary care physicians to ensure that necessary care is provided when and where it is needed, in a manner patients can understand (American College of Physicians).
A primary care medical home is foundational within the value-based healthcare model. Several organizations, including The National Committee for Quality Assurance (NCQA) offer recognition or accreditation programs for PCMH. A practice may also be recognized through several state-based programs. Regardless of the accrediting body, the Joint Principles (2007) of a medical home include 1) a personal physician for each patient 2) physician directed medical practice 3) whole person orientation 4) care that is coordinated or integrated across the system 5) quality and safety measures that are regularly monitored and reported, and 6) access for care as needed. The 7th Principle is reimbursement for delivery of personalized, coordinated services. The goal of PCMH accreditation or recognition is to encourage and support practice transformation into a medical home and focus on quality improvement.
NCQA offers the most widely adopted PCMH recognition program in the country. Its 2017 Standards were recently released on April 3rd. The program has been significantly redesigned, eliminating the previous levels of recognition and re-structuring requirements into Concepts, Competencies and Criteria. To achieve recognition under PCMH 2017, practices must 1) meet all core criteria and 2) earn 25 credits in elective criteria across 5 of 6 concepts.
The 6 Concepts are:
- Team-Based Care and Practice Organization
- Knowing and Managing Your Patients
- Patient-Centered Access and Continuity
- Care Management and Support
- Care Coordination and Care Transitions
- Performance Measurement and Quality Improvement
In the PCMH model, team-based care frequently includes a care manager/care coordinator charged with coordinating care for high risk patients, often those with chronic conditions. In larger practices, there may be additional staff to focus on population health management. Care coordination (sometimes called health navigation) may be handled by non-licensed team members, particularly when addressing social and non-medical needs. Increasingly, practices are hiring health coaches to engage patients and families in their care and improve self-management support. Regardless of team size or the function of each role, a primary focus is patient-centered communications that engage and activate patients and families so that they can understand and participate in their health care decisions. Health coaching creates a “spirit” of communication that encourages trust and relationship-building between provider and patients. Whether called a care manager, patient navigator or health coach, coaching skills can directly support each team members’ contribution in addressing the 6 Concepts.
Within each of the 6 Concepts are Competencies, – commitments and actions that often require additional knowledge and training to ensure the skill to complete the requirement. Health coaching responsibilities and skills support many of the NCQA required and elective competency criteria, particularly those under the Concepts of “Knowing and Managing your Patients”, and “Care Management and Support”. Examples include:
Under Knowing and Managing Your Patients:
- Competency A: Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools, and supports for the practice and for specific individuals.
- Competency C: The practice proactively addresses the care needs of the patient population to ensure needs are met.
- Competency D: The practice addresses medication safety and adherence by providing information to the patient and establishing process for medication documentation, reconciliation and assessment of barriers.
- Competency E: The practice incorporates evidence-based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients.
- Competency F: The practice identifies/considers and establishes connections to community resources to collaborate and direct patients to needed support.
Under Care Management and Support:
- Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/caregivers to develop care plans that address barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.
Under each Competency is a list of both core and elective criteria. For the benefit of patients and their families, these criteria must become more than a “task list” or “check the box” to meet the NCQA requirements. By implementing health coaching, the criteria spur meaningful outreach and valuable points of connection. From the patient’s perspective, health coaching changes the culture of the practice, and helps build trusting relationships. This enables providers to learn what truly motivates patients in improving their self-management and ultimately their health outcomes.
Additional information about the NCQA 2017 standards, click here (put the link in below).