Building integrated delivery systems in the safety net: Innovations in implementation of patient-centered medical home in ten California counties

Objective: Implementation of the patient-centered medical home (PCMH) is most feasible in an integrated delivery system with significant infrastructure to support care delivery according to the PCMH ideals. This challenge is greater within the safety net because of resource constraints and low levels of provider integration. Ten California counties participated in a Medicaid Waiver demonstration program that required creation of provider networks and assignment of enrollees to a medical home. The objective of this study is to examine the level of integrative services provided by participating counties to support the PCMH model. Study design: Participating counties were surveyed on the provision of the elements of an integrated system of care. The surveys focused on quality of care; specialty care; and HIT availability, functionality, and interoperability. Population studied: Ten California Counties participating in a Medicaid Waiver to provide health care to their low income uninsured populations between 2007-2010. Principal findings: Continuous quality improvement committees were formed by 9/10 counties and included hospitals and clinics frequently (6/9) but infrequently included patients (1/9).Quality monitoring was conducted using chart review (9/10) and claims/encounter data (8/9). Fewer reviewed clinical outcomes (7/9) or HEDIS measures (5/9) than utilization patterns (9/10). Nine counties evaluated specialist wait times, but 3/10 also considered distance or travel time. Six repeated this evaluation monthly or quarterly. Ophthalmology, gastroenterology, and orthopedics were the top highest demand specialties. Telemedicine (5/10) was used to increase specialty care access most frequently in ophthalmology (4/5). Eight out of 10 counties had some form of HIT but all still used some paper records. Of these, 4 had implemented full or partial electronic medical records. Order entry and electronic prescribing (5/8) was more common but only one county had a patient portal and another had provider messaging capabilities. Most common data elements in HIT systems were lab results (8/8) and imaging results (7/8), but abnormal test result alerts and reminders for medications (3/8) or preventive services (2/8) were less common.Conclusions: The findings provide evidence of significant effort by the counties in this study to support delivery of care under the PCMH model and illustrate the potential of safetynet providers to implement aspects of integrated delivery systems. Safety-net providers can provide certain features of integrated systems of care to facilitate PCMH care delivery. The experiences of early adopters such as those examined in this study are needed to guide such efforts nationwide.