Preparing for the medical home transformation

Preparing for the medical home transformationPhoto used with permission from

Medical homes are considered one of the most promising experiments under way to improve the quality of care and lower costs. The concept has been gaining momentum and shows no signs of slowing.

The principles of the medical home model aren’t new and are geared to ensure that patient-centered care is comprehensive and coordinated, and that it enhances patient access and focuses on the provision of quality and safe care.

The concepts of the medical home require a team-based approach that utilizes health information technology to identify and assist with the management of patient populations while allowing for the measurement of clinical outcomes. Although many of the principles and concepts of the medical home model are part of the day-to-day operations of the small primary care practice, the full adoption of the model can appear overwhelming. Solo practitioners and small practices must deal with a combination of scarce staff resources, small operating budgets and large demands to meet volume targets under fee-for-service payment. Those factors make it less feasible for small practices to hire extra staff (such as a nutritionist, data analyst or care coordinator) to support and sustain the transformation.

Although these barriers are real, they are not insurmountable. With appropriate planning and development, a small practice can achieve a successful medical home transformation. The following areas deserve attention if your practice is considering pursuit of medical home status:

Practice education – It’s important that each member of the practice care team fully understand the concept and principles of a medical home. This knowledge drives buy-in and promotes active participation in the successful transformation.

Practice roles -- Utilize limited resources to maximum abilities and scope. First identify what each team member is currently responsible for and look for opportunities to align responsibilities across the team to match skill sets. It’s important to utilize each staff member to his/her fullest capabilities in this team-based approach.

Care team responsibilities – Clearly define the role each team member will play in the medical home and develop the processes that support the following medical home concepts:

  • Patient tracking and follow-up;
  • Patient and caregiver education;
  • Health promotion and wellness care;
  • Care coordination;
  • Clinical outcome and performance monitoring; and
  • IT support and EHR system management and configuration.

Relationships within the medical neighborhood – Identify the community resources outside of the practice that provide specialty care, care management, hospital services, home care and behavioral healthcare. You must be able to coordinate and effectively manage your patients’ care. Establish formalized relationships with these resources to define referral protocols and follow-up processes, as well as admission and discharge coordination services. Think in terms of streamlining these processes.

Enhanced payment programs – Many payers across the country offer enhanced reimbursement for primary care providers that receive NCQA PCMH recognition with the purpose of providing financial support to assist the small practice in increasing necessary staff and services to support the medical home.

EHR configuration and utilization -- The cornerstone to success is to ensure your EHR is working for you. Having an in-depth understanding of how your EHR works and flows is key to streamlining clinical processes in the office. In addition, configure your system to provide meaningful care alerts, pertinent decision support, patient education materials and customized documentation templates to optimize workflow.

Health information exchanges – An HIE can serve as an excellent resource for collecting comprehensive clinical information for your patient population. HIEs build a “community record” of sorts; that record aggregates the pertinent information from specialists and hospitals, provides diagnostic testing results geared to quickly give primary care practitioners the information needed to assist in managing their patients’ care.

Engaging the practice to make a “system-wide” transformation can be challenging, but with appropriate planning and development the small practice can successfully transform into a true medical home.

Pam Minichiello is project director for the Massachusetts eHealth Collaborative (MAeHC). Courtney Beach is a practice consultant with MAeHC.

Photo used with permission from