Partnering between a health plan and community health centers to implement the patient-centered medical home

Health care costs in the US are rising to unsustainable levels while health and disease outcomes are well below many other developed-nations. Health care delivery is disjointed, uncoordinated, reactionary, and confusing. As an attempt to improve the current state of the health care system, the patient-centered medical home (PCMH) initiative has been gaining momentum.

Beginning in 2006 with a desire to improve the health of vulnerable populations, decrease cost per capita, and improve patient experience, CareOregon, a Medicaid managed care organization in Portland, Oregon, launched a medical home transformation collaborative. The initiative, Primary Care Renewal, consisted of 5 pilot healthcare organizations in Portland that worked to implement the fundamental principles of PCMH: dedicated leadership, population-level data, and the ability to organize work into teams. This model of primary care has improved disease outcome measures and decreased inpatient utilization by 16%.

The collaboration between the payor and the local safety net clinics has allowed for concrete development of curriculum and tools, a place to convene and share best practices, and financial support of the transformation, making the pace of transformation and spread faster. The curriculum includes leadership training and staff training on team development and process improvement. Tools are designed for organizations to use immediately in adapting the concepts of PCMH into their clinics and were designed from early experience in the community.

CareOregon has recently launched a new learning collaborative with 8 health care organizations throughout Oregon who are in relatively early stages of PCMH implementation. As an example of a participant in the collaboration, Neighborhood Health Center (NHC) is implementing the curriculum and tools, which has lead to a faster process of empanelment, team building, and process improvement than earlier clinics experienced. With the support of the collaborative, NHC is implementing proactive panel management in diabetes, hypertension and health maintenance.

Implementing the patient-centered medical home model has been shown to improve patient outcomes and decrease cost, while addressing the needs of the whole person. A partnership between a health plan and community health care organizations to implement PCMH can accelerate the pace of improvement by supporting partner organizations through an exciting but difficult transition.