PCMH: The Picture on the Outside of the Box for Primary Care Improvement

PCMH: The Picture on the Outside of the Box for Primary Care Improvement

Improved value, lower cost

The fundamental concept behind many of the primary care transformation models is simple: improve clinical outcomes within a reasonable price point. While Patient-Centered Medical Home (PCMH) may not be the silver bullet to all your operational struggles, it may be a worthwhile reference to use at various points along your journey.

PCMH is a team-based, delivery care model that provides proactive and comprehensive health care through active patient partnership. It is a framework that keeps practices focused on the big picture and the role that various team members play in driving outcomes. Its utility is that it can guide your improvement work, whether you are just starting down the path or looking to refine a function or skill. This was the primary theme discovered in the comprehensive Milliman study, “aside from being the right thing to do . . . the PCMH model provided organizations a clear roadmap for primary care transformation.”

No doubt your underlying goals to improve primary care are consistent with the objectives of these innovation models. The approach you use to meet those goals is where flexibility comes in. To create great health outcomes the focus needs to be on creating great processes that have the capability to yield these types of results. So, what does a primary care process that achieves this type of outcome look like?

Leveraging its Utility

PCMH provides a way to create contrast between your practice and the elements of what we know as one of the more successful delivery models that we understand today. One of the more difficult parts is taking a best practice or solution from another and integrating it into your practice’s context. Staying close to the best-known way to solve problems, first, give yourself time to understand the characteristics of:

… your population:

  • What is the burden of illness in different populations?
  • How does this degree of prevalence compare to what you would witness in a typical population?
  • What patients are at higher risk of uncoordinated, fragmented care?

… your practice:

  • What information do your care teams use to drive proactive interventions?
  • Did the programs we put in place last year create the results we were expecting?
  • Is provider variation due to population characteristics or how medicine is being practiced?

… your peers (enter PCMH model):

  • How do others manage 24/7 access?
  • What roles do various team members play?
  • What tools and resources are used to manage test results and referrals?

Without a framework like PCMH, there is no picture on the box to help you know if you are just making improvements or making improvements that matter to your patients, providers and staff. And while we know that one strategy or tactic alone will not solely determine performance, the interaction and sum of these methods will. So, beyond improved clinical outcomes, operationally there are reasons to support its use:

  • Improve relationships with specialty care physicians
  • Improve awareness of and referral to community-based resources
  • Improve reputation
  • Possible increased patient adherence to care plans
  • Bolster population health management and improvement efforts
  • Potentially reduce medical liability insurance

PCMH provides a common language to contrast between primary care delivery models and pinpoint practices that correlate with improved quality and cost healthcare. Delivering value to our customers is one of our core values. We take aligned steps to support you to be on the forefront of primary care innovation models like CPC+ and the newly announced Patient Care First. Our technical platform, that is widely used in the Direct Primary Care Space and has received NCQA PCMH Prevalidation status, is aligned to these objectives and your pursuit of improving primary care. We look forward to continuing this conversation on redesign and best practices in the primary care setting to drive population health.


Renee Towne

About the Author
Renee Towne
Director of Quality Programs at KPI Ninja, Inc.
Renee provides operational leadership of quality initiatives at KPI Ninja. Towne has a background in occupational therapy, education and experience in operational excellence across a variety of healthcare domains. Based on prior experience as a clinician that drove outcomes patient by patient, she is leaving a larger footprint by improving health care more comprehensively, population by population.


About KPI Ninja
KPI Ninja is a data analytics company that helps healthcare organizations accelerate their quality, safety, and financial goals with a unique combination of software and service. We are differentiated by our signature mix of technology, performance management consulting and healthcare expertise. We don’t merely offer software solutions but work shoulder to shoulder with clients to help them draw on the power of analytics and continuous improvement methodologies to become more efficient. In harmony with our data-centered ethos, we truly believe that our success is strongly co-related with yours.

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