PCMH standards have focused thus far on improved access to and coordination of medical services. Diverse stakeholders, including Federal and State agencies, insurers, physicians and other clinicians, employers, and patient advocacy organizations, are engaged in numerous efforts to promote primary care practice transformation into PCMHs through payment reform, practice support, and recognition programs (Maxfield et al., 2008 Berry, 2009 Adams et al., 2009 CMS, 2009 Deloitte, 2008 PCPCC, 2009 Qualis, 2009). The patient-centered medical home (PCMH) is a model for strengthening primary care through the reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care that is continuously improved through a systems-based approach to quality and safety (AHRQ, 2011).
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In light of widespread problems with primary health care in the U.S., many policymakers have called for major improvements in primary care as a key element of successful health care reform. This paper explores the current landscape of PCMH services for patients with complex needs, details five programs that have addressed the challenges of caring for these patients, and offers programmatic and policy changes that can help smaller practices better deliver services to all patients, including those with the most complex health needs. Smaller practices, however, face particular challenges in coordinating care for these patients. Patients who have complex health needs require both medical and social services and support from a wide variety of providers and caregivers, and the patient-centered medical home (PCMH) offers a promising model for providing comprehensive, coordinated care. At Mathematica, we thank Deborah Peikes, Erin Taylor, and Arnold Chen for providing overall direction and support throughout the project. Thanks also to Becky MacAninch-Dake Anne Shields, MHA, BSN and Juneau Whittaker of the Washington State Department of Social and Health Services, who shared details of the Washington State Medicaid Integration Program (WMIP).Īt the Agency for Healthcare Research and Quality, Janice Genevro and David Meyers provided very helpful comments and guidance during the development of this paper. Rich, Jr., MD (Cape Fear Valley Medical) and Jennifer Wehe (Community Care of Western North Carolina). Master, MD (Commonwealth Care Alliance) Skip Radwany, MD (Summa Health System) Cherylee Sherry, MPH (Minnesota Health Care Homes) Robert L. We would also like to thank the following experts for sharing their important work and for allowing us to describe their programs: Kyle Allen, DO (Summa Health System) Chris Collins (North Carolina Office of Rural Health and Community Care) Paul Cook (Community Health Partnership) Lori Feia (Community Health Partnership) Denise Levis Hewson, MSPH, RN (North Carolina Community Care Networks, Inc.) Carolyn Holder, MSN, RN (Summa Health System) Richard Hudspeth, MD(Community Care of Western North Carolina) Marie Maes-Voreis, RN, MA (Minnesota Health Care Homes) Robert J. Sean Morrison, MD (National Palliative Care Research Center, Brookdale Department of Geriatrics and Adult Development, Hertzberg Palliative Care Institute, MountSinai School of Medicine) Howard Tuch, MD (Suncoast Hospice) Don Liss, MD (Independence BlueCross) and Leslie Tucker (American Board of Internal Medicine Foundation). Charlie Lakin, PhD(University of Minnesota Rehabilitation Research and Training Center on Community Living) Walter Leutz, PhD (Brandeis University) R. We would like to thank the following members of the expert panel for their helpful perspectives and insights in the preparation of this white paper: Richard Baron, MD (CMS Seamless Care Models Group, affiliated with Greenhouse Internists at the beginning of the project) Michael Barr, MD (American College of Physicians) Tom Bodenheimer, MD (University of California at San Francisco) Christine Cassel, MD (American Board of Internal Medicine) Lisa Iezzoni, MD (Harvard Medical School, Mongan Institute for Health Policy at Massachusetts General Hospital) K. 12-0010-EF.Rockville, MD: Agency for Healthcare Research and Quality.
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White Paper (Prepared by Mathematica Policy Research under Contract No. Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions.
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Rich E, Lipson D, Libersky J, Parchman M. None of the investigators has any affiliation or financial involvement that conflicts with the material presented in this report. Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders. This document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document.