Establishing Federal Resources to Support Patient-Centered Medical Home Concept (New Jersey)

Project Details - Ended

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Summary:

Proponents of the Patient-Centered Medical Home (PCMH) model expected it to transform primary care by improving the health of populations and decreasing costs. This project developed a conceptual framework and communications infrastructure to serve as a base for the Agency for Healthcare Research and Quality (AHRQ) and others in the Federal government to conduct research and develop recommendations for the further development and implementation of this model of care.

The main objectives of the project were to:

  • Monitor emerging efforts and knowledge using an environmental scan, leading to effective synthesis of the knowledge and issues emerging in primary care and other health policies that may affect PCMH to help policymakers understand emerging PCMH initiatives.
  • Make substantive contributions to fill gaps through the development of white papers on PCMH-related topics.
  • Provide administrative support for work by AHRQ and the Federal Government to identify Federal activities relevant to medical homes and how they relate to each other and emerging private sector initiatives, facilitated by convening the Federal Collaborative for the Patient Centered Medical Home.
  • Develop a strategic plan that identifies how AHRQ can contribute to developing public and private sector work to improve primary care delivery.

In order to meet these objectives, the project team undertook several activities. These are described below:

Medical Home Definition:A definition of the medical home was created in close collaboration with AHRQ as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes, including being patient-centered, providing comprehensive care, providing coordinated care, providing superb access to care, and having a systems-based approach to quality and safety.

Environmental Scan:The project team completed a comprehensive literature review and environmental scan. In addition, they reviewed nearly 100 Web sites for content related to the medical home. From this work they created and updated a comprehensive searchable database containing more than 780 citations for resources on the medical home. These resources include journal articles, reports, policy briefs, selected newsletters and trade publications, and position statements.

White Papers:With input from expert panels, decision makers, researchers, practitioners, and advocates, the team developed a series of white papers. These included: Engaging Patients and Families in the Medical Home; Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home; Necessary, But Not Sufficient: The HITECH Act's Potential to Build Medical Homes; Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms; and The Medical Home: What Do We Know, What Do We Need to Know? A Review of the Current State of the Evidence on the Effects of the Patient-Centered Medical Home Model.

Decisionmaker Briefs:Several short briefs were developed that summarized selected white papers for easy dissemination.

Evidence Reviews:Eighteen evidence reviews of 16 models of the medical home were completed. Each summary contains four sections that address these questions: what was evaluated, how it was evaluated, if the model worked, and what is on the horizon.

Federal PCMH Collaborative:The project team helped to develop the Federal PCMH Collaborative steering committee, with 172 members representing 14 agencies and departments. The committee advised AHRQ on meeting topics, knowledge gaps on the PCMH, and how the Collaborative could meet the needs of members. In addition, the team developed content for the Federal PCMH portal, which is accessible only to members of the Collaborative.

Each of these activities filled gaps in the conceptualization and understanding of key components of the medical home model. In summary, the project team made substantial contributions to the PCMH knowledge base and a solid foundation for continued work in the field. The PCMH model is expected to transform primary care by improving the health of populations and decreasing costs.

Establishing Federal Resources to Support Patient-Centered Medical Home Concept - 2011

Summary Highlights

Summary: The patient-centered medical home (PCMH) model is a promising strategy for transforming primary care and improving the effectiveness, efficiency, quality, and patient experience of health care. This project supported the Agency for Healthcare Research and Quality (AHRQ) and the Federal government in: 1) developing the PCMH evidence base for researchers and policymakers; and 2) establishing a conceptual framework and communications infrastructure that AHRQ can use to develop recommendations for PCMH design, implementation, and evaluation.

A medical home is not simply a place; it is a model for organizing the delivery of primary health care. AHRQ recognizes the central role of health information technology (IT) in operationalizing and implementing the key features of the medical home. Additionally, AHRQ notes that building a primary care delivery platform that the Nation can rely on for accessible, affordable high-quality health care will require significant workforce development and fundamental payment reform. Without these critical elements, primary care's potential will not be achieved.

Project Objectives:

  • Conduct an environmental scan that synthesizes PCMH knowledge and issues in primary care and health policy in order to help policymakers understand emerging PCMH initiatives. (Achieved)
  • Develop white papers to fill knowledge gaps on PCMH-related topics. (Achieved)
  • Convene the Federal Collaborative for the Patient-Centered Medical Home to identify relevant Federal and private sector medical home initiatives and how they relate to each other. (Achieved)
  • Develop a strategic plan to leverage Federal leadership and activity in developing public and private sector work on PCMHs. (Achieved)

2011 Activities: The majority of project objectives were achieved in 2010. The focus in 2011 was on developing a final report, including a description of the relevant medical home initiatives and how they relate to each other. The project was completed in March.

Impact and Findings: Over the course of the project, Dr. Peikes and her team convened the Federal Collaborative for the Patient-Centered Medical Home, consisting of 172 members representing 14 agencies and departments. The collaborative builds a common body of knowledge and fosters collaboration among the many Federal agencies that focus on primary care. Throughout this project, experts were convened to advise the project team on the conception and formulation of a series of white papers as well as a list of key foundational articles for decisionmakers.

The white papers focused on topics such as patient engagement, mental health integration, health IT, and the medical neighborhood. The papers were well received by both researchers and policymakers and helped to fill gaps in the conceptualization and understanding of key medical home concepts. In addition to the white papers, other materials were developed to fill knowledge gaps on PCMH-related topics, including:

  • A briefing on care coordination in the PCMH.
  • A series of decisionmaker briefs.
  • A presentation at the 2011 AHRQ Annual Conference on the state of current and future research needs titled, "Patient-Centered Medical Homes: What Do We Know and How Can We Learn More".
  • A scan and assessment of 99 Web sites for content related to the medical home.
  • A database of citations listing the leading resources on the medical home, categorized by topic, population, bibliographical information, and keyword.
  • A list of foundational articles to help decisionmakers understand the emergence of and latest thinking on the medical home.

In addition to filling knowledge gaps, the papers, briefings, and PCMH portal Web site provided key information about how the PCMH model of care can achieve the triple aims of improving the health of the population, enhancing the patient experience of care (including quality, access, and reliability), and reducing-or at least controlling-the per capita cost of care. Together with AHRQ, the project team made substantial contributions to the PCMH knowledge base, building a solid foundation for continued work in this field.

Target Population: General

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient- centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Synthesis and Dissemination

Establishing Federal Resources to Support Patient-Centered Medical Home Concept - 2010

Summary Highlights



Target Population: General

Summary: This project supports the efforts of the Agency for Healthcare Research and Quality (AHRQ) and the Federal government to develop the evidence base on the patient-centered medical home (PCMH) for researchers and policymakers. The PCMH model is a promising strategy for transforming primary care and improving the effectiveness, efficiency, quality, and patient experience of health care. The goal of the project is to establish the foundation for a conceptual framework and communications infrastructure that will help AHRQ develop recommendations for PCMH design, implementation, and evaluation.

Project Objectives:
  • Conduct an environmental scan that synthesizes PCMH knowledge and issues in primary care and health policy in order to help policymakers understand emerging PCMH initiatives. (Achieved)
  • Develop white papers to fill knowledge gaps on PCMH-related topics. (Ongoing)
  • Convene the Federal Collaborative for the Patient-Centered Medical Home to identify relevant Federal and private sector medical home initiatives and how they relate to each other. (Ongoing)
  • Develop a strategic plan to leverage Federal leadership and activity in developing public and private sector work on PCMHs. (Achieved)

2010 Activities: This project reconvened the Federal Collaborative on the PCMH to improve coordination and collaboration among Federal agencies working on PCMH-related projects. The collaborative includes more than 172 members representing 14 agencies and departments. Members communicate through face-to-face meetings, a Federal portal that allows electronic interchange and document sharing, and a listserv that allows members to share information, ideas, articles, and announcements about events of interest.

A catalog of Federal agency activities and research related to the patient-centered medical home was developed. This resource includes a variety of information on agency efforts including implementation work, research being conducted, and partnerships with other agencies. This guide will help agencies in forming new cross-agency partnerships and will serve as a reference guide for finding Federal peers with PCMH knowledge on specific topics. One version of the guide was created specifically for Federal collaborative members; another version will be made publicly available.

This project also developed a publicly-accessible PCMH Web site (www.pcmh.ahrq.gov) for policymakers and researchers, at which foundational papers and background information from this and other projects are posted.

In response to AHRQ’s request, the project team also contributed to AHRQ’s mid-course review of their PCMH work to better reflect the emerging needs of government and private-sector stakeholders, and emerging policies from health reform in future work.

Preliminary Impact and Findings: The project has provided information for medical home stakeholders, including Federal and State agencies, policymakers, payers, patients, providers, and the media.

The project filled gaps in the conceptualization and understanding of key medical home concepts by working with AHRQ to develop the following outputs.

  • A series of white papers on patient engagement, mental health integration, health information technology, and the medical neighborhood.
  • A briefing on care coordination in the patient-centered medical home and the accountable care organization for AHRQ and for a meeting of key health care decisionmakers that was sponsored by the Patient-Centered Primary Care Collaborative.
  • A series of decisionmaker briefs.
  • A gathering of experts to advise the project on the conception and formulation of the white papers as well as a list of key foundational articles for decisionmakers.
  • A presentation at the AHRQ annual conference on the state of current and future research needs.
  • Quarterly updates to a database of citations listing the leading resources on the medical home, categorized by topic, population, bibliographical information, and keyword.
  • A list of foundational articles to help decisionmakers understand the emergence of and latest thinking on the medical home.
  • A definition of the medical home.
  • A list of key outcome articles on the PCMH for the AHRQ PCMH Web site.
  • Text for AHRQ’s public and private (Federal only) portals on PCMH.

Strategic Goal: Develop and disseminate research and conceptual frameworks and facilitate Federal collaboration to support patient-centered care, enhanced primary care, and the electronic exchange of health information to improve quality of care.

Business Goal: Synthesis and Dissemination

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