Participating primary care providers must complete a practice self-assessment, including a detailed work plan and appropriate time-line, leading to recognition as a patient-centered medical home by the National Committee for Quality Assurance (NCQA) at level two or higher within one year from the beginning of the pilot.  For more information on NCQA standards.

Providers must fully participate in the activities of the pilot.  These activities include full participation in one of the “pods” as well as attending meetings, completing assigned tasks, and providing necessary practice information.

Additional requirements include: relate to enhanced access to care, coordination of care/disease management, post hospitalization/ER care, evidence-based guidelines and measurements, and quality reporting and data sharing.

• Access to care
  Providers will assign each patient to a personal clinician who will provide continuity of care.  Same day appointments will be available to patients requiring urgent care, and patients will also have 24/7 phone access to the practice.
• Care coordination/disease management
  Providers will create a dedicated care coordination/disease management team to care for patients with chronic diseases that will initially include diabetes, coronary artery disease, hypertension, and asthma.  In addition to the primary care physician, the care coordination team will include an RN, pharmacist, dietitian, and licensed clinical social worker.  Each patient with a clinically important condition (as defined by NCQA) will receive evidence-based care to achieve NCQA level 2 recognition.
• Post hospitalization/emergency room care
  Post-acute care patients will be actively engaged by the assigned primary care clinician and care coordination team to facilitate effective transitional care, medication review and reconciliation, and appropriate follow up care.  The cases of patients with potentially avoidable hospitalizations or frequent emergency room visits will be flagged for review by their personal clinician to determine if changes are needed in the delivery of care.
• Evidence Based Guidelines and Measurements
  Practices with adult patients must include at least diabetes and their choice of two (2) of the following clinical topics for NCQA recognition: hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, or depression.  Pediatric practices must choose well child care/prevention and at least two (2) of the following: overweight/obesity, asthma, ADHD.  Practices with combined populations of adults and children will identify the clinically important conditions per NCQA recognition requirements.
• Quality Reporting
  Providers will participate in an organized disease registry and develop data reporting capabilities to enable reporting on access to care, clinical process measures, clinical outcome measures, and patient experience of care using common metrics and methods.

Providers who join a participating practice are automatically considered participants for purposes of the pilot.  Providers in newly organized practices within participating counties may apply to the Governance Committee to request participation in the demonstration.

Clinical Goals/Benchmarks

As stated above, the pilot seeks to improve care and contain costs for several high-risk, high-frequency chronic conditions (diabetes, hypertension, coronary artery disease and asthma). These conditions were chosen based on region-specific clinical and insurance claim data.

For the general patient population, primary care practices will focus on providing preventive care, age-and-sex appropriate screenings, and counseling. These include annual physicals, routine immunizations, pap smears, mammograms, colonoscopies, pediatric lead screenings, smoking cessation programs, and counseling for diet and depression. Primary care providers will proactively contact patients to schedule appointments and strive to keep patients on schedule for future routine examinations and screenings.

During the initial months of the pilot, specific clinical benchmarks will be set for the chronic care conditions. Utilization benchmarks will also be set for reduction of emergency room visits, inappropriate hospitalizations and length of stay in the hospital. The pilot will also set goals for the screenings and preventive services listed above.

Information regarding the pilot’s success in reaching goals will be made available in the News section of this website.