Patient Centered Medical Home

How does it improve patient experience?

The NEQCA Medical Home is led by the patient’s personal physician who works with a care team to coordinate continuous and comprehensive care.  For example, through the care management program, high-risk patients engage with a nurse case manager to learn how to manage their health and become active participants in their treatment.  

What does it mean for a physician practice?

The Medical Home helps to improve quality and efficiency performance, improve provider and staff satisfaction, and achieve Meaningful Use attestation for electronic health records and Patient Centered Medical Home National Committee for Quality Assurance (NCQA) Recognition Level II or Level III.

The goal of the program is to promote adoption and use of electronic health records to reduce cost and improve the quality and measurement of care.

The NEQCA Medical Home Program includes three main components: Meaningful Use, Patient Centered Medical Home (PCMH) System of Care, and Care Management.

Meaningful Use (MU) is the set of standards created by the Centers for Medicare & Medicaid Services (CMS) that defines three Stages of MU where eligible professionals attest to meeting those MU requirements to receive federal incentive payments.  These are short-term, performance based incentive programs, which govern the use of Electronic Health Records (EHR) and allow eligible providers and hospitals to earn incentive payments by meeting specific quality criteria.  Some of the requirements include: e-Prescribing, secure electronic health exchange of patient information, and submission of the Clinical Quality Measures to CMS. The goal of the program is to promote adoption and use of electronic health records to reduce cost and improve the quality and measurement of care.

Patient Centered Medical Home (PCMH) System of Care includes making changes in primary care practice workflow and processes to meet the requirements of the National Committee for Quality Assurance (NCQA). These standards provide guidance for workflow processes that support the delivery of high quality care, manage medical expenses, improve patient health, and increase physician and staff satisfaction as well as patient engagement. Care coordination is an essential component of the PCMH System of Care and requires additional resources, such as health information technology training for staff, and provides appropriately coordinated care through team-based models.

Care management provides additional help to primary care physicians (PCPs) to assist them in managing the highest-risk patients within the identified HMO population.

Care Management consists of a Care Team including:

  • Integrated Care Manager (RN)
  • Associate Integrated Care Manager (LPN)
  • Clinical Pharmacist
  • Care Coordinator
  • Behavioral health support from Tufts Medical Center Department of Psychiatry
High-risk patients have complex needs and require significant time from their primary care practices. Under the guidance of the physician, the Care Team completes a high-risk patient assessment and collaboratively develops an individualized care plan that focuses on medical intervention and measurable patient education. The care plan supports increased self-management by the patients, better coordination of care, use of community resources and improved adherence with testing and treatment, all of which result in optimal patient health outcomes in a cost effective manner. 

Early results from our work show that patients who work with a care manager have fewer visits to the emergency room, and that there is a trend towards fewer hospitalizations and lower costs of care when compared to similar patients not enrolled in the program.