A key role of leaders during PCMH transformation is to identify and allocate resources to best support PCMH transformation needs. Resources include time, dollars, staffing, equipment, technology and other types of support that either help staff implement or sustain PCMH key changes . Engaged leaders are physically present throughout transformation and sustain staff energy and motivation by working with staff to identify and remove barriers to transformation. Engaged leaders create a work environment supportive of PCMH transformation and give staff protected time and tools to make changes.
Key changes for Engaged Leadership:
Provide visible and sustained leadership to lead overall culture change, as well as specific strategies to improve quality and spread and sustain change.
Ensure that the PCMH transformation effort has the
Implementing care teams is a critical element of transforming a practice into a patient-centered medical home. A care team is a small group of clinical and non-clinical staff who, together with a provider, are responsible for the health and well-being of a panel of patients. Who is on the care team and their specific roles will vary based on patient needs and practice organization.
Key changes for Continuous and Team-Based Healing Relationships:
Establish and provide organizational support for care delivery teams accountable for the patient population/panel.
Link patients to a provider and care team so both patients and provider/care team recognize each other as partners in care.
Ensure that patients are able to see their provider or care team whenever possible.
Define roles and distribute
The relationship between the patient/family and the provider/care team is at the heart of the Patient-Centered Medical Home (PCMH) Model of Care.
Empanelment is the act of assigning individual patients to individual primary care providers (PCP) and care teams with sensitivity to patient and family preference. It formalizes and affirms these partnerships and sets the stage for all of the other components of effective PCMH practice.
For many practices, empanelment is a cultural transformation. Providers and care teams must shift their focus from caring for individual patients to managing the health of a defined population of patients. Empanelment also requires a shift from reactive to proactive care. The goal of focusing on a population of patients is to ensure that every established
Patient-centered interactions are considered one of the most important elements of the PCMH model. It involves the active expression of patient-centered care. Patient-centered organizations respect patients’ values and preferences, engage them and their families in healthy behaviors, and expand care capacity to equitably serve patients and families of diverse cultures and with diverse needs. To effectively respond to patients’ values, preferences, and needs, and to improve their experience of care, patient-centered medical homes need feedback from patients and families on the care they deliver.
Elements of Patient-Centered Interactions
Respect patient and family values and expressed needs.
Encourage patients to expand their role in decision-making, health-related behaviors, and self-management.
Communicate with their patients in a culturally appropriate manner, in a language and at a level
The Stage 2 Final Rule (CMS-0044-F) changed the way shared Certified EHR Technologies are handled for the Stage 2 measure option for summary of care records at transitions of care and referrals. Previously, if multiple EPs are using the same certified EHR technology in different physical locations/settings (e.g., different practice locations), there must be a single test performed for each physical location/setting.
The intent of the objective is to demonstrate that a provider has the full capability to use their certified EHR technology to successfully transmit a summary of care document to a different EHR vendor in a live setting.
Under changes made in the Stage 2 Final Rule providers that use the same EHR technology and share a network for which