bulb and team of paper manLeah Brunie, RN MSN FNP-BC, guest speaker at our Practice Transformation Seminar, shared her “10 Steps to Surviving the PCMH Process.” Leah is a Family Nurse Practitioner at Summit Family Physicians—a level 3 NCQA Patient Centered Medical Home and Comprehensive Primary Care Initiative practice located in Middletown, Ohio. Leah is the PCMH lead for her practice and shares this list of helpful tips to those practices considering PCMH recognition:

1. Communication is key in any quality initiative.

Don’t underestimate the importance of team meetings, provider meetings, team huddles, newsletters, etc. All of these are critical to the success of the PCMH process.

2. Identify a point person in your organization to be the leader of PCMH.

Determine who is going to own the process and help the practice transform.  People do not like change and are usually more comfortable with the old way of doing things. Therefore, this person must become the cheerleader of the process. They must work alongside staff, remain positive, and always behave in a way that reinforces the new culture.

 3. Everyone needs to work at the highest level of their ability.

The first step is to educate all team members. Practices must identify core educational materials and teach all of the staff. PCMH will not work effectively unless everyone decides to be a team player. 

The patient should be reinforced by the entire care team and given the same educational material. It is a good idea to use posters and/or color-coded info sheets to educate patients by hanging on the wall or having them available in the waiting room.

 4. Allow staff to help create their own workflows.

They are the experts of their departments, treat them as such by giving them the latitude to use their own judgment and create their own plans. The goal is to work smarter not harder, which can be achieved if executed correctly.

 5. Utilize the resources available and identify staff’s strengths.

It is always a good idea to have a trained MA to provide Care Coordination in the office. Care Coordination involves risk stratification—all high risk patients. (I.e. Diabetics with hgb A1c > 9—provide diabetic classes, provide one-on-one with care coordinator, schedule monthly appointments, reach out to patients.)

The job of the Care Coordinator can include preventative care, medicine reconciliation, labs and vaccine status, development and dissemination of education materials and training, identification and development of staff strengths, etc.

6. Choose measures that are meaningful to your practice, that will improve patient’s lives, outcomes, and decrease healthcare costs.

One example is ED utilization, which can cost $3000 to $4000 per visit. It is a good idea to implement open access/on call. The RN can call every patient that has been in the ER to assess reason for visit, reconcile medications, educate on open access, schedule follow-up if needed and/or assist with referrals.

7. Document and celebrate your success and patient’s successes.

Make it a team effort to celebrate the success of patients. Hang up CPCI poster and document when points are accomplished. Go after the low hanging fruit first (i.e. Meaningful Use points, policy in place). 

It is highly likely that your practice has always provided good care to your patients. With CPCI and PCMH you will be able to document, track, report and celebrate that care with your team and patients.

 8. Be creative.

Vendors are catching up, be sure to think outside-of-the-box. Create shortlists and smart phrases for your providers. Make sure the work you are doing is trackable and reportable. Be creative with your patient population.

 9. Get feedback from your patients on your practice.

Surveys are always a good way to do this. You could also create a “Patient Advisory Council” to get direct feedback from your patients. Areas of interest could be: patient portal, healthy advice, phone system/scheduling, etc.

 10. Don’t forget it’s all about the patient.

It’s easy to get caught up in spreadsheets, dashboards, hga1c  reports, EHR reports, etc. But you can’t forget that those numbers are patient’s lives. The goal is to improve patient’s quality of life which in turn affects their family, co-workers, and the entire healthcare system.

PCMH is a lot of work and you will have trials and triumphs but in the end it is a model which will improve patients’ health, improve outcomes, and decrease healthcare costs.