Patient-Centered Medical Home

In 2009, Blue Cross Blue Shield of Michigan and its physician partners launched the nation’s largest Patient-Centered Medical Home designation program. Developed in partnership with doctors and physician organizations, the Patient-Centered Medical Home program is transforming the health care system into a model of efficient, cost-effective care centered around the patient.

Through the Michigan Blues’ PCMH program, patients are receiving improved preventive care and higher quality of care, which helps them stay healthy and meet their health goals. An analysis shows that this model has saved $155 million in its first three years, due to avoided emergency room visits and hospital stays.  Blue Cross Blue Shield of Michigan estimates the program saved more than $100 million in year four.

The Value Partnerships PCMH model follows these principles:

  • Physicians will deliver higher-quality, lower-cost care when they use processes and tools that engage patients in a team approach to managing their health, and when they coordinate care for patients and give them access to care in the right setting.
  • Patients who have full access, including after hours, to their primary care physician will be more likely to receive the care they need in the appropriate setting, and will decrease their use of the emergency department for non-emergency conditions.
  • Primary care physicians who effectively manage their patients’ chronic conditions may help prevent hospitalizations, thus improving care outcomes and decreasing costs.
  • Physicians can more effectively manage their patients’ health through the use of secure, electronic patient registries and performance reporting tools.

In 2014, the Michigan Blues designated more than 4,020 physicians in more than 1,420 practices across the state as patient-centered medical homes based on their progress in implementing PCMH capabilities and qualities, and based on high performance on quality and use measures.

PCMH-designated physicians earn an enhanced fee for office visits, to compensate them for the extra time and effort required to practice as a medical home.

The PCMH model emphasizes coordination across all points in the patient’s care experience. Blue Cross has launched the PCMH-Neighbor model for specialist physicians who incorporate patient-centered characteristics and coordinate with PCMH practices.

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Patient-Centered care includes behavioral referrals for grief

I received the call from the PCP’s office referring the patient for distress due to the loss of her husband. On the referral form, there was a note regarding a history of alcohol abuse and current severe depression. I made contact with the patient and set an appointment for the following day.

My intake sheet asks if the patient is married, for how long and, if no longer married, why not. I was struck by the patient’s entry, “Husband died, by me”. Why, ‘by me’ I asked? She tearfully said his family blames her for his death because, when he collapsed at home, she did not apply effective CPR. I told her that, even when done well, CPR was likely to succeed only a small fraction of the time. I then went through her husband’s medical status, they were preparing to bring oxygen into the home for him for his emphysema, and reassured her that there was little she, or anyone, could have done. It was not her fault.

Her crying had stopped, but her mood was still very low. “He was my best friend,” she said. “The family took down all the pictures of us, and replaced them with pictures of him with his former wives.” I reflected that she and he had been very close for well over 20 years of marriage. I suggested she could probably imagine what he would do or say in almost any situation. She agreed. I asked her to imagine that he was standing behind her and, as she turned to him, he would tell her what he thought about how his family was behaving. She began laughing before she turned.

Over the course of the hour I spent with her, I could relieve her of her guilt over her husband’s death, I was able to explain the nature and progress of human grief, and show her that she was actually on a normal track. I could suggest that, though he was dead, he was not wholly gone, as she could talk to him any time and even hear his replies. The comfort he always provided, he could continue to provide. She agreed to come back for another session, and left with a distinctly lighter mood.

Being able to spend an entire hour at a time is one of the luxuries of my practice. Being able to sense and respond to the many factors driving the patient is one of the skill sets of my work. Driving toward sustainable outcomes that allow the patient to live more effectively with whatever challenges they face is my overarching goal. I have the time, and the skills, to do this kind of work, and this is what makes the behavioral specialist referral effective for the patient, and the PCP.

It’s another reason why the Michigan Blues’ Patient-Centered Medical Home Program is encouraging physicians to include behavioral health professionals as part of the care team.

Kenneth L Salzman, PhD, is a psychologist in the Lansing, Michigan area

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Behavioral health is key component of patient-centered care

It’s time we brought behavioral health assistance out of the shadows and into the full complement of primary care services to aid whole patient recovery and quality of life. Engaging a care team is a logical way to do this. 

Med Net One Health Solutions has embedded nurse-led care management teams in 15 practices throughout southeastern Michigan as part of the CMS primary care transformation demonstration project (MiPCT).  One of the project’s missions is to assess PCMH effectiveness. With the addition of the embedded care team, the primary care physicians continue to take the lead role in their patients’ care, but are able to make referrals to behavioral health specialists within the care team to help address the patients’ psychological and social needs.

 For example, in a busy downriver primary care practice with two physicians, two physician extenders and a patient population of 11,000, the practice was alerted through its hospital notification system when “Betty” was released from the hospital following a cerebral vascular accident. The embedded R.N. Care Coordinator reviewed all discharge notifications and promptly contacted Betty to perform a medication reconciliation and assessment before alerting the practice’s multi-disciplinary care team of primary care physician, social worker and registered dietitian.

 In addition to the need for physical therapy and dietary services, it was learned Betty was dealing with her husband’s alcoholism and experiencing feelings of social isolation and depression. Betty was counseled by the social worker through weekly phone calls; the social worker also connected her with local agencies to obtain social interaction and light housekeeping.

 Ultimately, the social worker and care team helped Betty recover physically and emotionally, and she avoided a hospital readmission. Without direct access to an embedded care team and a behavioral health specialist, Betty’s physician may have been unable to fully address her overall health issues. 

 Ewa Matuszewski is CEO of Med Net One, an Oakland County healthcare management organization

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Blue Distinction Total Care Brings Value to Other States

Millions of Michigan patients are receiving higher-quality, more cost-efficient care because of the work we do together in the Value Partnerships programs. These innovative care delivery programs are recognized for improving health care quality in Michigan.

Yet historically, these programs have been available only to our members in Michigan, which poses a challenge for customers who have employees in other states.

Now, with the launch of a new national designation program called Blue Distinction Total CareSM, Value Partnerships programs will be integrated into a national network, giving Blue customers access to PCMH and other quality programs from Blue plans across the country.

Blue Distinction Total Care links these various models across the country through a shared platform, so that we can offer our national customers seamless access to local innovations.   Beginning in 2014, programs from 26 states will be available; the program will continue to expand in 2015 and beyond.

While this is a robust national approach, the program is distinctively local and tailored to address the unique needs of members and providers in each community.

PCMH designated practices in Michigan will automatically meet the criteria and receive the national Blue Distinction Total Care designation. Additionally, providers participating in BCBSM’s Organized Systems of Care program will be recognized as Blue Distinction Total Care provider in the future. 

Shaun Raleigh is manager of Health Care Value National Solutions at Blue Cross Blue Shield of Michigan.

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History and results of the PCMH program – A three-part series

Blue Cross Blue Shield of Michigan’s Patient-Centered Medical Home program is noted for being the largest designation program in the U.S.  Thanks to the tremendous collaboration among participating physicians and physician organizations, it has also shown stellar results. 

PCMH physicians, as compared with non-PCMH physicians, have lower rates of primary-care sensitive ER visits for both adult and pediatric patients.  They have lower rates of  ambulatory-care sensitive hospital stays for adult patients.  The program has saved $155 million in the first three years, because patients are staying healthier and have better access to their PCMH doctors, avoiding costly ER and hospital visits.

David Share, MD, MPH, senior vice president, Value Partnerships at BCBSM, talks about the PCMH model of care and the keys to this program’s success in a three-part podcast series.  Listen here:

Part one -

Part two -

Part three -

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Establishing Context Around BCBSM’s PCMH Savings

The Patient-Centered Medical Home (PCMH) model of care is one approach to transforming primary care currently being tested in the United States.  The recently published May/June supplement in the Annals of Family Medicine shared practice transformation stories and challenges from groups around the country working to establish the PCMH model.  One of the common themes arising from these groups was the recognition that practice transformation is a journey.  It’s important to distinguish between practicing as a PCMH and being recognized as a PCMH, perhaps best embodied by these two statements: 1) “A practice could be a true PCMH without having received recognition, and a practice that has received PCMH recognition may not be a true PCMH,” and 2) “There is no Cinderella moment when a practice suddenly realizes it is a PCMH”.

Here’s why that is important.  Several previous studies have focused on PCMH as an ‘all-or-none’ phenomenon relying on comparing PCMH recognized practices to practices not recognized as PCMH.  Since PCMH is a transformative, evolutionary process, there are many intermediate stages in the spectrum of PCMH.  As a result, these ‘all-or-none’ comparisons that were intended to estimate the effects of the PCMH model may instead reflect differences in the stages of getting to a full PCMH model. 

This framework helps explain the study findings in the recently released Health Services Research Journal article “Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs” about the effects of PCMH we observed for the BCBSM PCMH program.  The article describes the association between PCMH capabilities and quality and cost measures. It finds that the degree to which the medical home model is implemented is positively associated with better quality of care and lower costs of care.  We found that even when the PCMH model is only partially implemented, there are significant associations with better quality of care and lower cost of care for adults as well as better quality of care for children.  We also found that the incremental improvements made during the course of a year were associated with even better quality of care. 

The advantage of this approach is that it allows us to estimate the full effects of PCMH, as well as the impact of the incremental changes and intermediate steps to becoming a PCMH.  So, even for practices just beginning their PCMH transformation journey, we can estimate the impacts they are having with their patients well before they become a fully transformed medical home.

Michael Paustian, Ph.D., MS, is a health care manager in the Clinical Epidemiology and Biostatistics Department at Blue Cross Blue Shield of Michigan.

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How are we transforming health care?

Launched in 2012, three new Collaborative Quality Initiatives (CQI) are among the latest Value Partnerships program aimed at improving health care value.

The three CQIs are introduced in the fifth annual Partners in Health Care Report: Transforming Health Care.

Since 2005, the Blues have partnered with tens of thousands of physicians across the state – and nearly every hospital – through the groundbreaking Value Partnerships program. It’s a program that’s transforming health care in the state, improving quality and outcomes and bringing greater health care value to Michigan,” President and CEO Daniel J. Loepp said in the report’s introduction.

Following are examples of how Collaborative Quality Initiatives are making a difference:

  • The 33 hospitals on the BMC2 angioplasty CQI reported a 20-percent decrease in hospital deaths.
  • The Advanced Cardiovascular Imaging Consortiumreduced radiation doses by more than 60 percent.
  • The Michigan Surgical Quality Collaborative reported a 15-percent reduction in length of stay for hospital patients.
  • Four of the longest-running CQIs saved more than $232 million statewide over three years. BCBSM savings were over $70 million during this time period.
Three new CQIs launched in 2012

  • Michigan Arthroplasty Registry for Collaborative Quality Improvement, which aims to improve the quality of care for patients undergoing hip and knee joint replacement surgery.
  • Michigan Radiation Oncology Quality Consortium, which aims to determine which breast and lung cancer patients are most likely to benefit from intensity modulated radiation therapy.
  • Michigan Urological Surgery Improvement Collaborative, which is working with urologists across Michigan to improve health care outcomes for men with newly diagnosed cases of prostate cancer.
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