Resources
The Puzzle: Piecing Together Patient Centered Medical Care and School-Based Health Centers
No matter the challenges of earning patient-centered medical home (PCMH) accreditation, the careful documentation of policies, procedures, and practices that constitute high-quality primary care is beneficial to SBHCs.
Such a comprehensive assessment can foster better quality improvement processes, clinical practices, care coordination, and coding and billing, and ultimately, greater sustainability for SBHCs over time.
Regardless of the specific path chosen, this guide aids SBHCs in adopting key performance and quality improvement strategies that align with national and state-specific PCMH measures and standards.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement number U30CS09738-08-00, award title “Technical Assistance to Community and Migrant Health Centers and Homeless” for $450,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
Patient-Centered Medical Home Model
Payers and patients are demanding greater value for their investment in the current health reform landscape. The promising patient-centered medical home (PCMH) model has emerged to meet their needs. This model combines two core concepts of public health: patient-centeredness and medical homes.
- Patient-centeredness represents a shift in patient orientation from recipient to partner. The provider‘s role is characterized as collaborative, empowering, relational, communicative, respectful, and empathic.Qu
- Medical home emphasizes not a fixed address or person but essential primary care functions and attributes—access, coordination, quality, comprehensiveness—that contribute to the twin goals of an improved experience and better outcomes.
There are many definitions of PCMH, but we admire the Oregon Health Authority’s definition for its simplicity and clarity:
- Access to care: Patients get the care they need when they need it.
- Accountability: Recognized clinics are responsible for making sure patients receive the best possible care.
- Comprehensive: Clinics provide patients all the care, information, and services they need.
- Continuity: Clinics work with patients and their community to improve patient and population health over time.
- Coordination and integration: Clinics help patients navigate the health care system to meet their needs in a safe and timely way.
- Patient- and family-centered: Clinics recognize that patients are the most important members of the health care team and that they are ultimately responsible for their overall health and wellness.
Why Should SBHCs Pay Close Attention to this Reform Movement?
One word: sustainability. With a big boost from the Affordable Care Act (ACA), and largely through the Centers for Medicare and Medicaid Services (CMS) and state Medicaid agencies, national and state policymakers are aiming to foster integrated systems that deliver higher quality, better coordinated, and more cost-effective preventive and primary care across the entire population. PCMH is a popular tool for redesigning primary care practices in service to that aim.
National Recognition Programs
A host of patient-centered medical home (PCMH) recognition programs have emerged to evaluate health care practices against integrated medical home principles. The three most well-known and widely used are:
- National Committee for Quality Assurance (NCQA) PCMH Recognition Program
- Accreditation Association for Ambulatory Health Care (AAAHC) Medical Home Accreditation and On-site Certification
- Joint Commission (JC) Primary Care Medical Home Certification
Many states are adopting these standards to drive improvements in primary care practice. According to the National Academy for State Health Policy, as of December 2015, 23 states were providing enhanced Medicaid payments to medical homes;[i] 14 of these were multi-payer medical home initiatives. The Health Resources and Services Administration (HRSA), which oversees the public health care safety net, has invested financial and technical assistance to facilitate PCMH recognition among federally qualified health centers.[ii]
Note: Accrediting bodies bestow recognition through accreditation, certification, or recognition; throughout this resource, however, we will refer to the process as recognition.
[i] State Delivery and Payment Reform Map. (2015). National Academy of State Health Policy. Retrieved January 22, 2016, from http://www.nashp.org/state-delivery-system-payment-reform-map/
[ii] Selecting an Accreditation and/or PCMH Recognition Organization. US Department of Health & Human Services, Health Resources and Services Administration. Retrieved January 17, 2016, from http://bphc.hrsa.gov/qualityimprovement/clinicalquality/accreditation-pcmh/selection.html.
Is PMCH Right for You?
How can you tell whether PCMH recognition is right for you? And if it is right for you, how do you know which program to use? Consider:
The benefits. The benefits of engaging your SBHC in a formal PCMH recognition process are many. Though labor intensive, documenting your practice’s alignment with national standards can:
- potentially qualify your SBHC for enhanced payments (depending on state policies);
- demonstrate your SBHC’s commitment to providing high quality services;
- provide your SBHC with credibility and visibility to health plans and payers;
- standardize your SBHC’s clinical processes ;
- facilitate continuous quality improvement (QI) in your SBHC; and
- enhance staff education in your SBHC.
The challenges. Providers should be advised that pursuing formal PCMH recognition is a commitment of human and financial resources—and can be especially challenging for small teams. Time and money aside, some have reported other challenges in their pursuit of recognition. The most common of these are:
- insufficient information technology support to extract data and generate reports;
- PCMH standards in place but not easily documented;
- inability to arrange 24-hour, 7-day a week access to care;
- clinic orientation is predominantly acute care rather than comprehensive preventive care; and
- recognition process does not address the unique confidentiality needs of students.
Deciding on a Recognition Program
Before pursuing PCMH recognition, SBHC practitioners must assess their readiness. When deciding which options are best for your SBHC, ask the following questions:
- Is staff willing to commit to the process?
- Has the electronic health record been functioning at least six months prior to initiating the process?
- Is PCMH recognition a requirement of payers, regulatory agencies, and/or managed care organizations in my state for reimbursement, certification or licensure, or as an element of participation agreements?
- Does the SBHC medical sponsor already have or is in the process of pursuing PCMH recognition for its community clinics? If so, have they considered including the SBHC(s) in that process?
- Will the SBHC qualify for higher reimbursements or enhanced payments from Medicaid or other payer for PCMH recognition and, if so, is there a particular PCMH recognition process required?
- Is the SBHC already accredited by JC or AAAHC and therefore familiar with the process? Receiving PCMH recognition through that same organization would then be an add-on to that process.
- What is the cost versus benefit of the recognition process and is there financial support for pursuing it? As mentioned above, HRSA financially supports FQHCs in obtaining recognition.
CASE STUDY: SHERIDAN HEALTH SERVICES, SHERIDAN, CO
Background
Sheridan Health Services is a federally qualified health center (FQHC) that includes a school-based health center and community clinic. The University of Colorado School of Nursing operates both clinics. Sheridan began the process of obtaining NCQA PCMH recognition for the sites in 2013. They selected NCQA because it seemed to be the most common choice among other FQHCs. In addition, Colorado Community Health Network, the state organization for community health centers, was providing no-cost technical assistance to support the recognition process.
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Challenges
Sheridan recently put the recognition process on hold because of the roll out of a new electronic health record, which is requiring tremendous energy and effort. They plan to resume their efforts for NCQA PCMH recognition soon. Their greatest challenges have been making the necessary changes to the electronic health record to meet the NCQA standards and finding adequate staff time to complete the process.
Impact/Lessons Learned
Sheridan Health Services’ staff members value the transformative process that has resulted from the process. Dr. Erica Sherer, CEO, explained that in her opinion, however, the NCQA PCMH model is not an ideal fit for SBHCs. “The benefit would be greater,” Sherer said, “if the focus was on youth engagement, better alignment with the school, and behavioral health.” She feels quality medical care is not their challenge. “The NCQA model is better suited for practices associated with large organizations looking at systems change,” she concluded (Erica Sherer, DNP, personal communication, February 18, 2016).
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CASE STUDY: WASHINGTON, DC
Background
Unity Health Care, Inc. is a federally qualified health center in Washington, DC. They operate a number of community health centers, including four school-based health centers. Three of their SBHCs have achieved Level 3 NCQA PCMH recognition. (The fourth was opened recently and has not yet gone through the recognition process.)
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Reason for Pursuing NCQA PCMH Recognition
The Health Resources and Services Administration encouraged FQHCs to adopt the patient-centered medical home model of primary care and supported the application process financially. NCQA collaborated with HRSA in this work.
The Approach Taken
According to Francina Boykin, SBHC Director, Unity Health Care, and Charlissa Quick, BSN, RN, MSA, School Health Division Chief at the Department of Health, (personal communication, June 1, 2016),
Unity Health Care, Inc. has a quality improvement team that includes clinical providers. The team was responsible for completing the NCQA PCMH application process for all of their clinics, including the SBHCs, in collaboration with clinic staff. They spent three years preparing.
Challenges
Ms. Boykin and Ms. Quick shared that NCQA staff had many questions about the SBHC model and whether it met the standards of PCMH. For example, NCQA staff needed clarification regarding the distinction between SBHCs and the school nurse program, particularly since school nurses are co-located at the SBHCs. They also had questions about whether the SBHCs continue to operate during school holidays like winter, spring and summer breaks when the schools are closed. In the case of Unity Health Care, the SBHCs do stay open during these periods.
Impact/Lessons Learned
Ms. Boykin encourages other SBHCs to pursue PCMH recognition. She says that SBHCs are already doing the work, so they might as well pursue recognition.
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CASE STUDY: HARRIS COUNTY, TX
Background
Harris Health System is a large network of hospitals and community health centers (CHCs) in Harris County, Texas. They operate multiple CHCs, including five school-based health centers in the greater Houston area. The SBHCs function as community clinics and can be accessed by all children in the community, not just students. All of the SBHCs are currently recognized as NCQA Level 3 patient-centered medical homes (PCMH).
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Reason for Pursuing NCQA PCMH Recognition
According to Dr. Richard Lyn-Cook, SBHC Medical Director, (personal communication, June 1, 2016), Harris Health System administration chose to pursue PCMH recognition as a way to continually improve the quality of care provided to their patients. They also wanted to have a competitive edge in the crowded Houston health care market and be well-positioned for payment reform under the Affordable Care Act. The NCQA PCMH recognition process was selected as they considered it to be the most robust and well-respected.
The Approach Taken
They first underwent the process in 2010. The medical director of the SBHCs at the time was tasked with spearheading the effort for all their clinics, including the SBHCs. The medical director became the in-house NCQA expert. She and her team combed through the NCQA manuals assessing what changes to data collection, workflow, and other processes were needed. They reached out to NCQA with questions. The medical director was co-located with the Information Technology (IT) department. This was helpful because the IT department was critical to the implementation of needed system changes and electronic health record modifications. They prepared for the process for six months and all their sites initially achieved either Level 1 or 2 recognition. Since that time, they’ve built on that foundation and now allow more time (9-12 months) to prepare for recognition renewal. All their clinics have currently achieved Level 3 recognition.
Challenges
Dr. Lyn-Cook shared that getting provider buy-in was one of their biggest challenges. The process required significant change on the part of the providers who were also implementing a new version of the electronic health record at the time. The other challenge was managing the additional work load put on staff. NCQA recommends that additional staff be hired to manage the transformation process but that in their case, that wasn’t possible. Instead, existing staff took on additional roles and responsibilities.
Impact/Lessons Learned
Since initially undergoing the process, Dr. Lyn-Cook reports that they have seen improvements in patient outcomes as measured by HEDIS indices, both for the adult and the pediatric population. He said that the recognition has “upped their game.” They think a lot more about improving the quality of care and regularly track their performance using data.
Dr. Lyn-Cook’s advice to other SBHCs is to recognize that the process requires a significant amount of work and that each SBHC needs to determine for themselves if the effort is worth the time and expense. He believes they were successful because they are affiliated with a large organization, had a dedicated person to lead the effort, and had sufficient IT infrastructure. He says that for smaller SBHCs, without an affiliation to a larger organization, it might be very difficult to achieve recognition. He recommends that those SBHCs implement quality improvement initiatives based on existing NCQA recommendations prior to formally applying. He added that he personally cannot imagine pursuing PCMH without the organizational support that Harris Health afforded him.
CASE STUDY: METRO COMMUNITY PROVIDER NETWORK (MCPN), JEFFERSON COUNTY, CO
Background
Metro Community Provider Network (MCPN) is a federally qualified health center that operates three school-based health centers in Jefferson County, Colorado. MCPN has prioritized PCMH recognition because they believe it drives payment reform and they also anticipate that it will soon be a requirement of payers. MCPN elected to pursue AAAHC medical home accreditation because it aligned more closely with outpatient primary care. (Note: they are currently pursuing NCQA PCMH Stage 3 recognition as well because they feel it has become the gold standard for FQHCs.) “If SBHCs want to be equal in today’s healthcare market, they need to come to the table as equals and do the work of recognition,” said Lynn Bakken, PNP-BC, MCPN Associate Medical Director of Pediatric and Adolescent Services (personal communication, January 29, 2016).
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The Approach Taken
It took approximately 12 months to prepare for the AAAHC onsite survey. A team lead spearheaded the process with a consultant provided at no charge by the Colorado Community Health Network. They formed a committee with broad representation from across the organization and divvied up the work of preparation. Their IT department was involved as well because the process required running reports and extracting data.
Challenges
MCPN’s biggest challenge was time because it involved a significant amount of work on the part of several people.
Impact/Lessons Learned
Ms. Bakken felt the AAAHC process was valuable to their SBHCs and other clinic sites. It provided an opportunity to discover ways to document many of the clinic processes that were already being done but not being captured. They revised several policies and procedures once they began scrutinizing them for patient education, team-based care, and patient engagement. The process also led to more standardization across providers and sites.
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CASE STUDY: TRUE HEALTH, CENTRAL FLORIDA
Background
True Health is a federally qualified health center operating seven clinics in central Florida, including two SBHCs at Maynard Evans High School and Cheney Elementary in Orlando.
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Reason for Pursuing AAAHC Medical Home Accreditation
According to Janelle Dunn, MHA, Chief Operations Officer, and Deana Montella, BSN, RN, Director of Nursing (personal communication, May 25, 2016), True Health chose to pursue AAAHC Medical Home Accreditation for three main reasons: (1) to increase the confidence level of their patients in the quality of the services delivered; (2) to distinguish True Health from other medical providers in the community; and (3) to be well-positioned for payment reform within the changing health care landscape. They considered Joint Commission Accreditation to be too hospital-oriented for their ambulatory care setting and thus AAAHC was selected.
The Approach Taken
True Health took a team approach to prepare for the onsite survey. They used AAAHC resources, such as their accreditation handbook and checklists. They also attended an AAAHC conference, which provided an excellent opportunity to network and learn from other practices who were already accredited. They shared clinical and administrative updates on progress at monthly management meetings. They received their first AAAHC Medical Home Accreditation in 2012 before either SBHC was in operation. Once the SBHCs were up and running, they submitted a letter to AAAHC requesting that the SBHCs be added to the accreditation. In 2015 they were reaccredited and AAAHC visited the SBHCs at that time.
Challenges
The biggest challenge they faced was assuring that all of their policies and procedures were aligned with AAAHC standards.
Impact/Lessons Learned
Ms. Montella and Ms. Dunn shared that since undergoing the accreditation process; they feel more confident that they are clinically and operationally on par with other high quality health care organizations. The accreditation has enhanced their relationship with the schools they work with and solidified their reputation. They also say that the accreditation has strengthened grant applications.
Ms. Dunn and Ms. Montella had the following advice for SBHCs planning to pursue AAAHC Medical Home Accreditation:
- Stay calm as it can be a stress-provoking process.
- Attend an AAAHC conference to help prepare because the networking opportunity is invaluable.
- Reach out to the helpful AAAHC staff with questions throughout the process.
CASE STUDY: HEARTLAND HEALTH CENTERS, CHICAGO, IL
Background
Heartland Health Centers is a federally qualified health center serving Chicago’s north side. They operate eight community health centers and six school-based health centers. Four of their SBHCs are well established in Chicago. Two additional SBHCs opened in 2015 in the village of Skokie, a northwestern suburb of Chicago. The organization decided to pursue Joint Commission (JC) accreditation and medical home certification because of their dedication to safety and high quality health services. They previously received JC Accreditation in 2013 and are up for renewal in 2016.
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The Approach Taken
Preparing for the JC onsite survey was a team effort. There are five managers for their 14 sites and they’d been working together to prepare. They utilized QI nurses to train the managers on the accreditation standards, including infectious disease control, CLIA waiver requirements, and safety. The managers then did tracers (or walk-throughs) of clinics they weren’t managing to assess compliance in the various areas. They recruited IT staff to pull data reports as needed. To meet PCMH certification requirements, Heartland invested in several program improvements. These included creating a patient portal, establishing care coordination teams, and implementing a system to assure students were scheduled, as often as possible, with the same primary care provider.
Challenges
The greatest challenge for the Heartland Health Centers has been coordinating preparation activities between five managers and 14 sites. In addition, clinic staff members are busy—so it could be a struggle to keep the process moving forward.
“We had some confusion and misunderstanding on the part of parents with the promotion of the PCMH model,” reported Maria Paredes, RN, Manager of the SBHCs (personal communication, March 14, 2016). As the importance of a primary care provider has been stressed, some parents feared losing their community provider if they accessed SBHC services. This has required ongoing education about the complementary role of SBHC services and PCMH.
Impact/Lessons Learned
Ms. Paredes believes the process has improved patient care, particularly follow-up and care coordination: “It was a good choice for us given the Joint Commission’s long history of assuring safety and quality.”
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Some states have created their own standards for patient-centered primary care (or medical) homes to innovate. For example:
CASE STUDY: COLORADO ACCOUNTABLE CARE COLLABORATIVE
Background
The Colorado Department of Health Care Policy and Financing (HCPF), the state Medicaid agency, began implementing the Colorado ACC in 2011 to “move from a system that rewards high volumes of services to one that rewards high quality of services and better health outcomes.” [i] The ACC is using the PCMH model of comprehensive, coordinated, team-based, and client-centered care as a building block.
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Under the model, primary care medical providers (PCMP), including physicians, nurse practitioners, and physician assistants, contract with the regional care collaborative organization (RCCO) in their practice area to serve as the medical home for assigned enrollees. PCMPs are responsible for providing health care services and assessing non-medical needs such as housing, behavioral health services, and social services. The PCMP and/or the RCCO help clients assess these services.
On top of standard fee-for-service payments, PCMPs receive a per-member/per-month payment (PMPM). They are also eligible for incentive payments for meeting key performance measures. An additional PMPM payment (called Enhanced Primary Care Provider Payment) is made if the provider can document doing at least five of the following:[ii]
- Provide appointments at least once a month outside of regular business hours
- Provide clinical advice by telephone or secure messaging during and after hours
- Use data to identify patients who may need extra services and support
- Provide onsite access to behavioral health providers
- Administer a behavioral health screening (including substance use) and/or developmental screening for children and has processes to address positive screens
- Maintain a list of patients receiving care coordination
- Track referrals to specialty care providers and provides the clinical reason for the referral along with pertinent clinical information
- Accept new Medicaid clients for the majority of the year
- Collaborate with patient/family to develop and update an individual care plan
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CASE STUDY: NORTHSIDE CHILD HEALTH CENTER, MONTROSE, CO
The Northside Child Health Center is a school-based health center located in Montrose, a small rural community on the western slope of Colorado. Northside opened in 2007 and serves as the pediatric safety net clinic for the community. The Montrose School District operates the clinic and employs the SBHC behavioral health provider, family outreach coordinator, and receptionist. They contract with Pediatric Associates to provide the medical services of a nurse practitioner. Northside also partners with the Montrose Community Dental Clinic to provide a dental hygienist part time onsite.
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For Northside, PCMP recognition through the Colorado ACC has the potential to increase their revenues and patient base, but it also allows them to be part of a larger movement to improve the health care delivery system. “It’s important that SBHCs be recognized as high quality clinics by holding themselves accountable to the same PCMH standards as other pediatric practices,” said Jennifer Suchon, MSN, PNP-BC, FNP-BC, Medical Provider and Clinic Director of the Northside Child Health Center (personal communication, March 8, 2016).
The Approach Taken
It took approximately 4-5 months to enroll with the local RCCO, Rocky Mountain Health Plans, once it was determined who would sign the contract (see Challenges below). They currently receive $3/month for each patient who selects or is assigned to the SBHC, in addition to fee-for-service reimbursement. They have not yet applied for Enhanced Primary Care Provider Payments but plan to do so in the near future. This will require that they undergo a practice assessment to document that they meet at least five of the nine criteria before receiving this additional payment.
Challenges
The biggest challenge for Northside was determining the terms of the RCCO contract. The RCCOs are accustomed to contracting with medical entities, which the Montrose School District is not. However, because the Montrose School District operates the SBHC and already had a contract with Rocky Mountain Health Plan, they decided that the Montrose School District would be the contractor. The contract does specify that the medical records are owned by its contracted provider, Pediatric Associates.
Impact
The overall impact has been positive. As predicted, they are generating increased revenues. Ms. Suchon also reports that the process has “nudged” them forward in terms of quality improvement. Their RCCO, which is also the Medicaid Managed Care Organization, requires regular Healthcare Effectiveness Data and Information Set (HEDIS) chart audits.
Being part of the RCCO has increased their visibility and credibility in the community. Ms. Suchon believes their participation will contribute to the long term sustainability of the SBHC as funders and that others will recognize Northside as a sound investment.
[i] The Accountable Care Collaborative. (2016). Colorado Department of Health Care Policy and Financing. Retrieved March 8, 2016, from https://www.colorado.gov/pacific/hcpf/accountable-care-collaborative-provider-information
[ii] Accountable Care Collaborative (ACC) Incentive Payments: Enhanced Primary Care Medical Provider definitions page. (2016). Retrieved March 8, 2016, from https://www.colorado.gov/pacific/hcpf/accountable-care-collaborative-acc-incentive-payments[/expand]
Four alternatives to patient-centered medical home (PCMH) recognition exist for non-traditional primary care practices: the NCQA Patient-Centered Connected Care (PCCC) Recognition, the New York School-Based Health Alliance Patient-Centered School Based Health Care (PC-SBHC), the University of Michigan Adolescent Health Initiative’s Adolescent Champion Model, and the Boston Children Hospital’s Care Coordination Measurement Tool (CCMT).
NCQA PCCC RECOGNITION
For health care “neighbors that surround and inform the medical home and colleagues in primary care,” NCQA developed the Patient-Centered Connected Care (PCCC) Program. The PCMH alternative for specialty practices focuses on access, communication, and care coordination. Its intended targets are retail clinics, urgent care centers, physical therapy, podiatry, optometry, chiropractic sites, and SBHCs that do not serve as the medical home.
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Like its PCMH cousin, PCCC recognition is based on five standards, each with several components. It is not yet clear how these standards or the providers who achieve recognition will be rewarded by health care payers.
TABLE 8: NCQA PCCC Standards and Elements
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Case Study: Health Delivery, Inc. Saginaw, MI
Background
Health Delivery, Inc. is a federally qualified health center located in Saginaw, Michigan, that operates multiple community health clinics and two SBHCs, both of which are included under the scope of services for the FQHC. Six of their CHCs currently have Level 3 NCQA PCMH recognition, and plans to get recognition for four more of their CHCs are in the works.
In Michigan, several Medicaid qualified health plans pay a per-member/per-month (PMPM) incentive to practices that are NCQA PCMH recognized. The PMPM is pro-rated based on the level of recognition achieved. Michigan Medicaid also requires PCMH designation for participation in the MI Care Team Project, a coordinated, team-based approach to caring for Medicaid beneficiaries. Lastly, Health Delivery, Inc. receives an additional federal stipend from HRSA based on the number of sites that have PCMH recognition.
Reason for Pursuing NCQA PCCC Recognition
One goal of the organization is for all sites to receive recognition from one of NCQA’s three programs: PCMH, Patient-Centered Specialty Practice (PCSP), or PCCC. “Because our SBHCs don’t serve as the primary medical home, we opted to go with the PCCC recognition,” said Angelia Williams-Welch, MSN, BSN, RN, Director of Special Projects at Health Delivery, Inc. (personal communication, November 18, 2015 & March 23, 2016). Ms. Williams-Welch explained that it’s unclear if PCCC recognition will satisfy the PCMH recognition requirements of Michigan payers. Though HRSA does not support the PCCC recognition process, the Michigan Department of Health and Human Services (MDHHS) is covering the cost of the PCCC application for the SBHCs as part of a pilot project.
The Approach Taken
Health Delivery, Inc. started working on the PCCC recognition process in the summer of 2015 and they anticipate it will take one year to complete. The team they formed to do the work is composed of Ms. Williams-Welch, SBHC providers, the QI coordinator for the organization, IT staff, and consultants for the Child and Adolescent Health Center Program at MDHHS.
Challenges
Williams-Welch identified the following challenges in the process:
- Time: It has been difficult finding sufficient time for the team to meet.
- Staff Turnover: The recent loss of an SBHC primary care provider has delayed the process.
- Lack of Expertise in PCCC Process: No one on the team was familiar with the PCCC recognition process.
- Documentation of Standards: As with other recognition programs, one challenge is documenting existing processes. Most of the processes outlined in the standards are in place but documenting it in a way that can be demonstrated to NCQA is challenging. For example, Health Delivery, Inc. had to revise and create new policies and procedures that align with the standards and elements.
Impact/Lessons Learned
Ms. Williams-Welch said that although the process has been painstaking at times, overall she feels it has been valuable, was a great learning experience, and gave them the opportunity to improve care. They have enhanced cultural competency and improved communication with external providers, among many other advancements. “The standards reflect what should be practiced in SBHCs,” said Williams-Welch, adding that having the recognition will be advantageous when seeking future grant opportunities. Her recommendations for other SBHCs wishing to pursue PCCC recognition are to:
- Include an IT person on the team to assist with pulling reports and data
- Engage a knowledgeable consultant to facilitate the process
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NEW YORK SCHOOL-BASED HEALTH ALLIANCE PC-SBHC
After completing a thorough comparison of several PCMH programs, collaborators from the New York State School-Based Health Alliance, the Montefiore Medical Center’s School Health Program, and the Primary Care Development Corporation concluded that the national recognition programs didn’t fit the work of SBHCs and, more importantly, lacked relevancy for SBHCs. And thus, the PC-SBHC 2014 Project was born. With funds from the Altman Foundation, their primary aim was to develop and pilot SBHC-specific PCMH standards. Using the NCQA PCMH standards, elements, and factors as a model, the group mapped a set of PCMH standards unique to SBHCs.
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The PC-SBHC model is composed of six standards, 27 elements, and multiple factors for each element. The six standards are nearly identical to the NCQA PCMH standards:
- Patient-centered access
- Interdisciplinary team-based care
- Population health management
- Care management and support
- Coordinate and track care
- Measure and improve performance
While there are many similarities, several NCQA PCMH elements have been revised or added to reflect preventive care and the population management strengths of SBHCs. The focus on electronic health record standards was deemphasized. Its creators say PC-SBHC’s objective wasn’t to make the recognition process easier, but to assure relevancy for SBHCs.
Case Study: PC-SBHC
The PC-SBHC standards were piloted in five school-based health centers in New York and two SBHCs in Connecticut in 2015. Participating SBHCs were required to use an electronic health record and adhere to Meaningful Use Stage 1. Pilot sites underwent a baseline assessment and received an individualized practice-specific work plan. Participating SBHCs then formed QI teams and were provided bi-weekly coaching and guidance on gathering documentation. It took anywhere from 12 to 18 months to complete the process depending on (1) time allocated by SBHC staff (weekly meetings versus twice a month meetings), and (2) where the SBHC was at baseline in terms of integration of PCMH principles.
Findings
- Many of the processes outlined in the standards were in place but not being documented in a way that could be demonstrated to others.
- There was much variation in the QI efforts of the pilot sites. They all found benefit in formally implementing QI processes and having data to support their efforts.
- The level of integration that an SBHC has with its sponsor has a strong effect on the SBHC’s ability to meet the standards.
Challenges/Barriers
The pilot sites identified a number of challenges and barriers, several of which are not unique to PC-SBHC. Rather, these are challenges most SBHCs will face when pursuing PCMH recognition—irrespective of the particular program.
- PCP-SBHC tension: There can be tension between the community primary care physician and the SBHC in terms of who is responsible for different aspects of a child’s care. There is often an assumption with PCMH that a single provider is responsible for patient care, but in reality, primary care responsibilities are shared.
- Small teams: SBHCs are generally staffed with a small number of individuals; finding sufficient time can be a constraint.
- Documenting standards: SBHCs had to design strategies to document many of the clinic processes that were already in place, but not captured, such as care coordination.
- Electronic health record functionality: While SBHCs utilized many of the features of their electronic health record, they discovered additional features and reporting tools to document various functions of patient care.
- Insufficient data support: PCMH recognition requires the ability to extract, analyze, and report data, but many SBHCs lack sufficient IT support to do this.
- Measuring standard of care: It was hard to identify the standard for preventive care that is provided to the patient. Many SBHCs are doing sick care/urgent care but it is more difficult to get a sense of what preventive care is uniformly provided.
Impact
- SBHCs made improvements in population management with the help of previously undiscovered electronic health record features.
- SBHCs modified existing processes or created new ones to improve clinic operations.
- SBHC staff improved communication through team huddles and other strategies.
- Sponsor organizations became increasingly aware that SBHCs should be included in QI processes, meaningful use, etc., and began to include their SBHCs in these efforts.
Lessons Learned
- Clinicians should be included on the QI Team because they are the ones implementing changes.
- A dedicated IT person who is familiar with how SBHCs operate is essential for PCMH transformation to help with data extraction and reporting, and to assist in implementing features of the electronic health record.
- Data are not only needed for QI. They can be very powerful for telling an SBHC’s story.
- SBHCs need to be empowered to ask for what they need from their sponsoring agency and be included in PCMH and QI processes.
Next Steps
The collaborators plan to pilot the standards in additional New York and Connecticut SBHCs in 2016. Their goal is to find a “home” for SBHC-PC Standards among one of the nationally-recognized accrediting bodies to create an option for SBHCs looking to become recognized as a PCMH.
To learn more about PC-SBHC, contact the New York School-Based Health Alliance at nysbha@gmail.com or visit their website at http://www.nyschoolbasedhealthalliance.org/.
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UNIVERSITY OF MICHIGAN ADOLESCENT HEALTH INITIATIVE’S ADOLESCENT CHAMPION MODEL
The Adolescent Champion Model drives health centers to become adolescent-centered medical homes. The Champion model is a multi-faceted intervention to address a health center’s environment, policies, and practices to ensure that all aspects of a visit to the health center are youth-centered. It includes: a facilitated clinic assessment that aligns with PCMH standards; HEDIS-based quality improvement initiatives; customized implementation plans; and recommendations and resources for improving clinical practice, including workflows, templates, trainings, and tools to measure impact across providers, health center staff, and adolescent patients. Additional information can be found here.
BOSTON CHILDREN HOSPITAL’S CCMT
This free tool developed by Richard Antonelli, MD, at Boston Children’s Hospital measures care coordination activities, resources needed to implement care coordination, and resulting outcomes. CCMT can be used by any personnel performing care coordination, including nurses, social workers, patient navigators, case managers, and primary and subspecialty care providers. It has been adapted for pediatric health systems in both ambulatory and in-patient settings. CCMT has also been cited in the AHRQ Care Coordination Measures Atlas. More information can be found here.