Patient centered medical home and chronic disease management in Pennsylvania

The Chronic Care Commission in Pennsylvania combined dissemination of the medical home model across the state with efforts to improve chronic disease management. Methods. Philadelphia area practices were invited to apply to participate in the Southeast Pennsylvania Collaborative (SEPA). Insurers offered to reimburse practices at higher rates if they obtained certification by the National Committee on Quality Assurance (NCQA) as patient centered medical homes (PCMH). Teams from each practice implemented practice improvements and reported monthly on outcome indicators. Diabetes reporting included the number of enrolled diabetics, percents with abnormal or elevated A1C, LDL, blood pressure, percent with self management goals, on recommended medications, and assessed vision and other complications. Results. Thirty five practices participated in the SEPA Collaborative; most focused on diabetes. Evidence-based practice improvements included disease registries, pre-planned visits, self management goal setting, and case management. Most practices included non-clinician staff in the clinical team; some added vision, and mental health services. All practices achieved NCQA certification as Patient Centered Medical Homes. At one year, there were improvements in several indicators: patients with A1C > 9 (32% to 26%), with A1C < 7 (33% to 44%), blood pressure < 140/90 (56% to 70%), LDL<130 (44% to 63%). The percent on recommended medications increased, as did those with assessment of complications of the eyes (21 to 36%), feet, and kidneys, and those with self management goals. Conclusion. Combining efforts to establish the medical home and the chronic disease management model can improve patient outcomes and expand access to recommended services.