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DIGESTM E D I C A L H O M E
N E W S F R O M T H E S A F E T Y N E T M E D I C A L H O M E I N I T I AT I V E
This issue of Medical Home Digest poses some frequently
asked questions about PCMH transformation: What
evidence supports the PCMH Model of Care? How should
we measure improvement? How can leadership set the stage
for successful transformation?
The issue begins with an article highlighting recent
recommendations from the PCMH Evaluator’s Collaborative.
The following article describes recent research on PCMH cost
and quality outcomes and offers thoughts on what is needed
to build the PCMH evidence base. The Digest continues with
an article that outlines essential leadership roles and behaviors
for effective transformational change. It concludes with an
announcement about a new public domain online resource
for practice facilitators built on the SNMHI framework.
Introduction
The Medical Home Digest is a newsletter devoted to
keeping you informed about medical home transformation
in the safety net. This newsletter is brought to you by the
Safety Net Medical Home Initiative, which is sponsored by
The Commonwealth Fund. Each issue highlights critical
aspects of patient-centered care and PCMH transformation.
Spring 2013
I N T H I S I S S U E :
Introduction .....................................................................................1
Measuring the Success of Medical Homes: Recommendations from the PCMH Evaluators’ ..................2
Evidence that the Medical Home Works ................................4
Essential Leadership Roles for
Transformational Change ............................................................5
New Guide for Practice Facilitators:
Coach Medical Home ....................................................................9 R E S O U R C E S :
Using a Patient-Centered Care Plan and Teamwork to Support Self-Management (March 28, 2013)Speakers: Larry Mauksch, MEd, LMHC, University of Washington Department of Family Medicine (Seattle, WA); Berdi Safford, MD, Family Care Network (Bellingham, WA)
Closing the Loop with Referral Management (February 26, 2013) Speaker: Linda Thomas-Hemak, MD, President and CEO, The Wright Center for Graduate Medical Education (Scranton, PA)
Tools to Enhance Patient Engagement (January 24, 2013)Speakers: Chris Delaney, MBA, Insignia Health (Portland, OR); Cathy Davenport, RN, BSN, PeaceHealth (Eugene, OR); Shannon Gilbert, MHA, MultiCare Health System (Tacoma, WA); Jim Weiss, MD, Primary Health Medical Group (Meridian, ID)
Planned and Mini-Group Medical Visits (January 10, 2013)Speakers: Devin Sawyer, MD, and Jamacca Larman, CMA, St. Peter Family Medicine Residency Program (Olympia, WA)
Spread and Sustainability in Medical Home Transformation (December 19, 2012) Speakers: Mindy Stadtlander, MPH, CareOregon (Portland, OR); Robert Reid, MD, PhD, Assoc. Investigator, Group Health Research Institute (Seattle, WA)
Safety Net Medical Home Initiative
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There are currently more than 90 commercial health plans, 42 states, and three Medicare initiatives testing the Patient-Centered Medical Home (PCMH) Model. Yet, while elements of the medical home have been shown to be associated with better quality and lower cost, there are only a few high-quality published evaluations of the impact of the PCMH model as a whole. There is an urgent need for rigorous information to strengthen the evidence base of the medical home in order to ensure effective implementation of the model.
PCMH evaluations can help clarify what’s working well, shed light on what needs improvement, and identify contextual factors that facilitate implementation. The purpose of medical home evaluations is not to issue a verdict about whether or not PCMHs “work.” Years of research from the U.S. and abroad show that strong primary care is essential to achieve high performance in our health care system. Alternatively, the goal of current PCMH evaluations is to learn from the numerous demonstrations and programs and help guide effective implementation that will lead to better patient care, lower cost, and improved population health.
In an effort to harness and share lessons from the many disparate medical home pilots and evaluations under way, The Commonwealth Fund established the Patient-Centered Medical Home Evaluators' Collaborative in 2009. The objectives of the Evaluators’ Collaborative are to:
1. Reach consensus on a standard core set of outcome measures and instruments;
2. Share the consensus on instruments, metrics, and/or methodological lessons with interested researchers around the country; and
3. Foster an ongoing and supportive exchange where evaluators share ideas that improve their evaluation designs, analytic approach, and interpretation of findings.
More than 85 researchers participate in the Evaluators’ Collaborative. To achieve consensus on a core set of measures, five work groups were developed to focus on key outcomes or domains: medical home implementation, patient experience, cost/utilization, clinical quality, and clinician/staff experience. Each work group reviewed the literature, developed logic models, and met regularly to debate effective and feasible measures to evaluate medical home pilots in each dimension. Given the importance of the patient perspective in evaluating the medical home, we created a separate workgroup that focused on patient experience.
In May 2012, the Evaluators’ Collaborative released its recommended core set of standardized measures for two of the five work groups: cost/utilization and clinical quality. The Official Summary Statement is posted on the Commonwealth Fund’s website. Table 1 on the following page summarizes the core set of measures to evaluate cost and utilization outcomes in PCMH evaluation studies. The minimum measurement set to monitor changes in utilization includes measures of emergency department (ED) visits, hospitalizations, and readmissions. For cost measures, there was consensus that evaluations should always include analysis of total per member per month cost for high-risk patients, since the PCMH initiative is most likely to detect a measureable effect on this patient population. While there was widespread agreement that measures should be risk-adjusted to account for complexity of the patient population, there was diversity of opinion about which method of risk-adjustment to apply.
In terms of clinical or technical quality outcomes, the Evaluators’ Collaborative reached consensus on a core set of principles. Due to concerns about variation in the emphasis of local PCMH pilots as well as diversity of PCMH pilot populations, a uniform minimum
Measuring the Success of Medical Homes: Recommendations from the PCMH Evaluators’ Collaborative
Melinda Abrams, MSThe Commonwealth Fund
Asaf Bitton, MD, MPHThe Commonwealth Fund
Meredith Rosenthal, PhD The Commonwealth Fund
continued
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quality measurement set was viewed as inappropriate. However, a core set of principles was intended to encourage rigor and flexibility, as well as consistency in reporting of technical quality by PCMH evaluators. Since the first principle calls for evaluators to use “standardized, validated, nationally recognized measures,” the Clinical Quality work group did put together a suggested list of measures from which PCMH evaluators could select items for their evaluations. For those evaluators interested in their data being used as part of a meta-analysis, the group did agree to a very limited, core set of clinical quality measures. Both the long list of technical quality measures and the short list of measures for possible meta-analysis are listed in the Official Statement.
Given the importance of the patient perspective in evaluating the medical home, a separate work group focused on outcomes measures to assess patient experience. This group conducted a review of various patient surveys being administered in a wide number of PCMH evaluations. The team also commented on the strengths and weaknesses of the various questionnaires as an evaluation tool. Ultimately, the findings of this work group were
incorporated into ongoing research by a team at Harvard, Yale, and the National Committee for Quality Assurance to develop and test the new PCMH-CAHPS survey (Consumer Assessment of Healthcare Providers and Systems), which was officially released by the U.S. Agency for Health Care Research and Quality in January 2012. The survey can be found here.
The PCMH Evaluators’ Collaborative continues to meet and is open to all researchers actively working on a medical home evaluation. However, it’s important to remember that efforts to reach consensus on a core set of standardized outcome measures for PCMH evaluation are only a small part of a much larger and broader spectrum of PCMH measurement. There are measures to monitor PCMH transformation (e.g., PCMH-A developed as part of the Safety Net Medical Home Initiative) and measures of accountability (e.g., NCQA or URAC measures for PCMH certification). We hope these recommended outcomes measures for PCMH evaluation will strengthen the quality of medical home research, inform future medical home implementation, and ultimately, improve primary care policy in the United States.
Table 1. Core Cost/Utilization Measures for Cross-Study Comparison in PCMH evaluations
Utilization
Emergency department visits, ambulatory-case sensitive (ACS) and all
Acute inpatient admissions, ACS and all
Readmissions within 30 days
Cost
Total per member per month costs
Total per member per month costs for high-risk patients
Technical issues: all utilization and cost issues should be risk adjusted; method of pricing should be transparent and standardized if possible
Source: The Commonwealth Fund PCMH Evaluators’ Collaborative.
Table 2. Core principles and measures for assessing clinical quality in PCMH evaluations
Quality Measurement Principles
1. Evaluators should use standardized, validated, nationally endorsed measures. The PCMH Evaluators’ Collaborative Quality Workgroup recommends selecting a group of quality measures from Table 3. For purposes of meta-analysis, we recommend the measures listed in Table 4 as a core set.
2. Evaluators should select measures from each of the following areas of primary care: preventive care, chronic disease management, acute care, overuse and safety.
3. Evaluators should apply a validated approach to data collection. This is particularly important if pulling measures from the medical record or EHR.
4. Evaluators should use consistent measures across practices within a demonstration.
Source: The Commonwealth Fund PCMH Evaluators’ Collaborative.
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If you’ve been on the medical home
transformation journey with us for the last
few years you’ve probably done a lot of work
organizing patient panels, improving access,
reorganizing staff into teams, and gathering
lots and lots of data. You are not alone.
Hundreds of patient centered medical home
demonstration programs are happening across
the country. Results about improvements in
care, patient and staff experience, cost saving,
and more are just starting to come in. The Commonwealth
Fund has been a leader in organizing data from different PCMH
programs so we can better compare the results and understand
what works and what doesn’t. For more on the PCMH Evaluators’
Collaborative efforts, see the companion article by Melinda
Abrams and colleagues.
Several recently published reports discuss early results of
these medical home transformation efforts.1, 2, 3 Though
only representing a portion of the medical home programs
sponsored by commercial health plans, state Medicaid programs,
foundations, federal agencies, and others, these reports do provide
a first look at the questions we are all asking about primary care
redesign. Does care improve? Are patient and staff experiences
bolstered? Are costs reduced?
The most convincing of these evidence reviews is a report
commissioned by the Agency for Healthcare Research and Quality
and conducted by researchers at the Duke University Evidence-
based Practice Center. The authors of this systematic review
sifted through more than 5,700 peer-reviewed papers to find and
carefully analyze 19 comparative studies. Across all studies, the
medical home showed some promising results:3
• Improved patient experience of care.
• Improved delivery of preventive care services.
• Improved staff experience.
• Reduced emergency department visits.
These findings are great news and a testament to the tremendous
amount of work required to become a medical home. However,
questions remain including improved health outcomes and
whether the medical home can reduce health care costs. Many
of the medical home programs included in this systematic review
had different operational definitions of what it means to become
a medical home. Some programs focused more on cost reduction
than others, and many of the programs had been underway
for fewer than two years. The authors conclude that there is
not enough evidence to be sure about the impact on clinical
outcomes or cost reductions. That means we need a lot more data
from sites about what is working and what is not!
As part of the Safety Net Medical Home Initiative, researchers
from the University of Chicago have been collecting data about
changes to patient health outcomes, cost, utilization of health
services, and patient and staff experience, as sites have become
medical homes. After the SNMHI concludes, researchers will
publish their findings, adding to a growing body of knowledge
about the effectiveness of medical homes and providing some of
the most detailed information yet on how medical homes work
for vulnerable populations. Keep your eyes out for these new
medical home papers!
1. Nielsen M, Langner B, Zema C, Hacker T, Grundy P. Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost and Quality Results. Patient-Centered Primary Care Collaborative. 2012. Available here.
2. Peikes D, Zutshi A, Genevro JL, Parchman ML, Meyers DS. Early evaluations of the medical home: building on a promising start. Am J Manag Care. 2012;18(2):105-16.
3. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178.
Evidence that the Medical Home Works
Katie Coleman, MSPHMacColl Center for Health Care Innovation
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Transformational change, like Patient-Centered
Medical Home (PCMH) transformation,
requires not only adapting new processes
and procedures, but attending to the way
people work and think together. Identifying
essential leadership roles and responsibilities
and setting up clear structures for
communication and decision-making help
to foster change-hardiness in yourself and
your team as well as create avenues on which
to move toward your vision.
Everyone is capable of being a leader—of influencing and
empowering action in a positive direction. In a primary care
practice, there are typically several leadership positions
including practice owners/Executive Directors, clinical leadership
(e.g., Medical Director, Nursing Director), and administrative leaders
(e.g., CFO, COO). There are also leadership roles (e.g., sponsor, team
leader, informal leaders). Successful PCMH transformation requires
senior leaders to support change efforts and provide necessary
resources to make and sustain those changes. Staff in leadership
roles, whether in leadership positions or not, also need to model
behaviors essential to achieving those changes.
This article provides an overview of common leadership roles
required to support large-scale change/transformation efforts and
provides tips and examples of supportive behavior for those in
leadership roles.
Engaged Sponsorship – a key to success
While all leaders may (and ideally, do) have formal and informal
influence upon a group, a sponsor has the means to support the
change in vital ways. An effective sponsor directs the distribution
of necessary resources (e.g., time, equipment, space, money), is
able to inspire enthusiasm in others to achieve goals, and has
the hiring/firing power to put capable people in the right roles.
An effective sponsor also desires the change as transformational
change requires determination and desire. In other words, a
sponsor is required to have resources, authority, and desire (RAD).
Often the sponsor is in the CEO/President position or owns and
directs the practice. Every major change effort requires a sponsor
in these capacities. Some practices have a team of sponsors. In
this case, it is essential to be clear about specifically who will be
the executive sponsor of your change initiative.
Project leader/team leader - While a team leader may not
have the authority to allocate resources (e.g., staff time, capital
expenses), an effective team leader can leverage his/her influence
to build a spirit of collaboration to keep the team engaged and
productive. The project leader may also be the team leader and
have staff on the team directly reporting to him/her. While project
leaders/team leaders are frequently the physician or nurse leader
of a quality team or the clinic manager, they do not need to be
in a formal position of authority. An effective team leader has the
ability to guide the team’s work and help the team stay focused on
the goal. A good team leader also attends to healthy interpersonal
dynamics in the team and therefore must have the team's respect
and trust. Additionally, staff in this role must have clear and
frequent communication with the sponsor as they are likely the
bridge between sponsor and team.
continued
Essential Leadership Roles for Transformational Change
Cynthia Manning, MAVibrant Consulting
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Informal leader/influencer - This staff member has a great deal of
influence and is often a leader regardless of official role. Influential
strength is gained through demonstration of ability and character;
they do what they say they will do and they are able to do it.
Project leaders will do well to encourage such people to play
critical roles on the change team, providing their influence is in
line with the strategic direction of the organization.
For every leader, leading a transformational change effort
challenges both your internal and external resources. While you
are in the thick of juggling myriad responsibilities, everything you
do, say, or do not do, even facial expressions, are magnified to
others working under your leadership. While observing you, your
team is busy consciously and unconsciously interpreting their
observations. Effective leaders strive to be keenly aware of their
impact, keep themselves and others focused upon the vision,
support systems, and processes to keep everyone moving in the
same direction. A leader must strive to walk the talk at all times.
A cinch, right?
Following is a review of some of the essential tasks required of
leaders engaged in transformational change. These tasks are not
necessarily sequential, and it is beneficial to repeat and review
them regularly.
Sponsor Tasks:
Clarify and build commitment to the vision.
• If sponsorship is shared within the organization, as may be the
case with an executive leadership team, it is essential that all
sponsors be in agreement with the vision. Responsibility for
the change project may be delegated to one person, but this
person must have the support of the executive team and board
of the whole organization.
• Evaluate your practice’s capacities. Do you have the necessary
resources to support making changes? Can you involve staff
in redesign meetings? Is there a budget for necessary
equipment/software purchases? Are you adequately staffed?
Do you have room in your budget to provide additional training
to staff when needed?
• Communicate to the organization a clear vision of your
practice’s desired state, including rationale for the need to
change. This may include presenting a formal business case.
Communication of a clear vision will need to be repeated
frequently through multiple modes (e.g., email, memos,
newsletter, message boards, meetings, employee
performance reviews).
• Clarify the major goals (both required and desired) for
the project.
Identify a leader for your change team.
• This person may be working in a day-to-day capacity in
the team, or they may be a facilitator from other areas of
your organization.
• They must have an ability to earn the trust of the team,
demonstrate competency and integrity, and have the skill to
facilitate team processes.
• The team leader must be able to advocate for team resources
and provide feedback and coaching to team members.
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Clarify the decision-making processes and authority of
the team.
• Since the final decision about changes rests in your authority to
sanction them, the project team needs to know how you want
the team to participate with you in decisions related to quality
efforts. Will you be making all decisions about what quality
efforts to engage in, who to involve, etc., or will you consult
with the team and then decide after you have seen evidence
and suggestions? Will quality efforts be decided upon by
consensus or majority rule? The decision-making process must
be consistent and transparent.
Set up regular progress report sessions with the team leader.
• This is a time for honest dialogue. Make it safe for the team
leader to bring up concerns and frustrations. Find solutions
collaboratively. This is also a time to acknowledge progress and
the accomplishment of project milestones.
Sponsor/Team Leader/Manager tasks:
Appoint the project team.
• Bring a cross representation of roles into the team. Given the
choice, invite those who work well with others and who have
enthusiasm for the project to be team members. Inviting the
recalcitrant in hopes of winning them over often results in the
need to apply a considerable amount of effort to keep them
positively engaged. Negative attitudes can have a very
negative impact upon team morale and even a team’s ability
to think creatively.
• Project team members need to know the scope of their
responsibilities and how their work on the team will be
balanced with everyday tasks. Will team members be relieved
of some of their everyday tasks to make adequate time for
their participation? The team needs dedicated time and
meeting space. Without time and space, a team simply
cannot do its work.
• Nurture two-way communications. Sponsors need to be kept
informed and the team needs to know what the sponsor is
thinking about progress. A crucial sponsor role is to remove
roadblocks to team progress (e.g., persuading staff to participate
in tests of change, creating time for the team to meet, providing
timely access to essential information).
Team leader tasks:
• Help the team agree upon processes for bringing up issues,
making decisions, and working through conflicts. Together,
create a shared vision and clarify meeting attendance
commitment. These become the group behavioral agreements
and charter and need to be reviewed and adjusted (when
necessary) on a monthly basis.
• Facilitate goal setting with the team. The major goals of the
project are the “big pieces” and set by the sponsor. Help the
team design smaller components of these goals, identify steps
to getting there, and influence the order in which they are
carried out. The team can and should apply their knowledge
and experience of how things work “in the real world” to discern
appropriate and effective tests of change.
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• The team needs to agree on how they will make decisions in
their efforts. Will they use majority vote or consensus? While
majority vote may seem faster at first, time is often spent later
managing the frustrations and disappointments of those
that have been over-ruled. The consensus process allows for
concerns and issues to be openly discussed and understood
from different points of view.
• Listen. Listen. Listen. Ask questions. If someone brings up
a concern, stay curious. Ask, “What would it look like if this
problem were solved?” Keep progress notes and charts visible
for the team and communicate to the team.
• Think small. Small tests of change by small numbers of
participants. Cross-functional project team meetings are
essential. In addition, the team can appoint a small sub-team to
meet on the fly and make small tests of change related to larger
project goals.
• All teams operate by agreements, either explicit or implicit,
which guide dynamics that impact how diverse roles or
opinions are included, how disagreements are handled,
how decisions are followed through, and so on. Foster the
team's understanding of change dynamics as well as their
understanding and appreciation of different styles and
perspectives. As the team grows in its ability to reflect and learn
together, it will become more effective and efficient in it's ability
to grapple with the myriad challenges that transformational
change offers.
• Teams need positive feedback. Members need to know
when they are doing a good job, and need to be recognized
and encouraged in their work. Team members sometimes
experience criticism from other employees who view team
meetings or “special projects” as goof-off time, or less valuable
than working on day-to-day tasks. Posting frequent updates
regarding team progress/changes can help build credibility
for team members and serve as a reminder that they are
making a difference.
A note to sponsors, team leaders, managers: You are a walking
broadcast of the tone and culture of your practice. How you
interact with everyone will be watched and recorded in the minds
of the team, and played back repeatedly. When you are ambivalent
or discouraged, the team will notice this and their commitment
will waver accordingly. Listen, listen, listen. People will respond
more positively to your earnest conviction if they experience being
listened to when they have concerns.
I M P L E M E N T A T I O N
SAFETY NET MEDICAL HOME INITIATIVE
Strategies for Guiding PCMH Transformation
I M P L E M E N T A T I O N G U I D E
ENGAGED LEADERSHIP
May 2013
TA B L E O F C O N T E N T SIntroduction .......................................................... 2 The Change Concepts for Practice Transformation: A Framework for PCMH ........ 2Chart the Course: Build Will for Change ............... 3 Make the Case ............................................... 3 Clarify Roles and Responsibilities ................... 5Case Study: Encouraging Leaders at Every Level ..................... 7 Develop Communication Strategies ............... 8 Generate Ideas, Foster Innovation.................. 8 Identify and Mentor Champions ..................... 9Use Data to Drive and Guide Improvement.......... 9 Support QI Teams ..............................................12Embed PCMH in the Organization .......................13 Strategic Planning ..............................................13 Hiring and Training ..............................................13Support and Sustain Change by Ensuring Adequate Time and Resources ............................15 Protected Time for Improvement ...................15 Financial Resources .......................................15Case Study: Leadership’s Integration of PCMH ..18Manage Change ..................................................19Conclusion .......................................................... 22Use Proven Strategies: The Institute for Healthcare Improvement’s Seven Leadership Leverage Points for Organization-Level Improvement ........................ 23Additional Resources .......................................... 27Appendix A: Examples of System-Level Measures ..................................... 31Appendix B: Health Information Technology ....... 32
IntroductionAn organization adopting the Patient-Centered Medical Home (PCMH) Model of Care is making a commitment to system-wide transformation. Staff at all levels of the organization must be willing to continually examine processes, adapt to change, and make improvements. These sweeping and transformative changes require the visible and sustained engagement and tangible support of a wide range of leaders including executive leaders (e.g., CEO, Executive Director), financial leaders (e.g., CFO), board members, funders, community supporters, and even payers.
Leaders drive change within their organizations from the top down and the bottom up. Leaders inspire providers and care teams to re-imagine care delivery and reconsider how the organization interacts with patients.
Leaders facilitate PCMH transformation by charting the course for change and supporting and sustaining change efforts. For PCMH transformation to be successful, leaders must provide the necessary time and resources, remove barriers, and provide continuous inspiration and motivation for staff. Most importantly, leaders must implement strategies that make change possible by fostering and encouraging a supportive environment for staff. While guiding their organization through transformation, leaders will need to develop specific strategies. Leaders will need to develop protocols for empanelling patients to ensure continuity of care, address pushback as care team members’ roles change, find ways to protect time for care coordination, and encourage staff to include patients and families on quality improvement (QI) teams.
Look for additional tips and strategies in the updated SNMHI
Engaged Leadership Implementation Guide, available now.
Additional Resources
Anderson LA, Anderson D. The Change Leaders’ Roadmap: How
to Navigate your Organization’s Transformation. San Francisco, CA:
Pfeiffer; 2001.
Scholtes PR, Joiner BL, Streibel BJ. The Team Handbook, 3rd ed.
Madison, WI: Oriel; 2003.
R Galford, AS Drapeau. The enemies of trust. Harvard Business
Review. 2003; 2 :88-95.
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Practice facilitation or coaching and learning communities
are proven clinical improvement strategies for successful
Patient-Centered Medical Home (PCMH) transformation. To add
to the body of publicly available knowledge about practice
facilitation, Qualis Health and the MacColl Center for Health Care
Innovation created the online curriculum: Coach Medical Home:
A Practice Facilitator’s Guide to Medical Home Transformation.
The curriculum is built on the Safety Net Medical Home
Initiative’s framework for practice transformation and designed
to help practice facilitators implement the PCMH Model within
the safety net. Content draws on lessons learned from the
Initiative’s practice coaches.
The goal of Coach Medical Home is to offer any practice
facilitator in any setting nationally support for their work with
patient-centered medical home transformation. To support
transformation, the curriculum contains real world, real-time
tools, and resources and consists of six modules. Each module
contains action steps for practice facilitators to implement
PCMH transformation, provides tips, and links the reader to tools.
Modules also include links to a PDF handbook and companion
PowerPoint presentation that can be easily printed.
The Coach Medical Home curriculum modules include:
Module 1: Getting Started instructs practice coaches on
establishing a relationship with a practice and kick starting the
transformation process.
Module 2: Recognition and Payment introduces key contextual
factors including payment and recognition that need to be
taken into account when working with a team to develop a
transformation strategy.
Module 3: Sequencing provides a framework and coaching
strategies for breaking the transformation process into
manageable phases and steps.
Module 4: Measurement describes the central role of
measurement in transforming care—including enabling teams
to identify priorities, monitoring progress, and keeping focused
on goals.
Module 5: Learning Communities introduces effective
strategies for encouraging teams to motivate, support, and
learn from each other.
Module 6: Sustain and Spread provides ideas for maintaining and
spreading the changes beyond the active PCMH transformation
period—focusing on long-term care improvements.
For more information visit: www.CoachMedicalHome.org
New Guide for Practice Facilitators: Coach Medical Home
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Safety Net Medical Home Initiative
This is a product of the Safety Net Medical Home Initiative, which is supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff. The Initiative also receives support from the Colorado Health Foundation, Jewish Healthcare Foundation, Northwest Health Foundation, The Boston Foundation, Blue Cross Blue Shield of Massachusetts Foundation, Partners Community Benefit Fund, Blue Cross of Idaho, and the Beth Israel Deaconess Medical Center. For more information about The Commonwealth Fund, refer to www.cmwf.org. The objective of the Safety Net Medical Home Initiative is to develop and demonstrate a replicable and sustainable implementation model to transform primary care safety net practices into patient-centered medical homes with benchmark performance in quality, efficiency, and patient experience. The Initiative is administered by Qualis Health and conducted in partnership with the MacColl Institute for Healthcare Innovation at the Group Health Research Institute. Five regions were selected for participation (Colorado, Idaho, Massachusetts, Oregon and Pittsburgh), representing 65 safety net practices across the U.S. For more information about the Safety Net Medical Home Initiative, refer to: www.qhmedicalhome.org/safety-net.