A geriatric patient-centered medical home: How to obtain NCQA certification
ABSTRACTThe patient-centered medical home is a rapidly growing concept in reforming American health care. It has spread from its origins in primary care pediatrics to family practice and, more recently, into internal medicine. This review article describes how primary care geriatricians can obtain certification from the National Committee for Quality Assurance (NCQA) for a patient-centered medical home that includes some of the features unique to geriatrics.
KEY POINTS
- The NCQA has six broad standards for patient-centered medical homes: practices must enhance access and continuity, identify and manage patient populations, plan and manage care, provide self-care support and community resources, track and coordinate care, and measure and improve performance.
- Each standard has a number of elements, of which six are “must-pass.” These deal with access, data for population management, care management, support for self-care, referral tracking and follow-up, and continuous quality improvement. All must be rigorously documented.
- Practices must identify three important medical conditions for continuous quality improvement.
- Applying for certification is hard work but, if accompanied by real changes to your practice, should improve the care you deliver.
The concept of the patient-centered medical home began as a solution for children with multiple chronic conditions.1 It has since been touted as a solution for all patients with chronic diseases, for problems with continuity of care, for restructuring primary care flow, for quality and safety, and for reining in cost.2–4 The key to the medical home concept is that the primary care provider helps to coordinate a patient’s care across a variety of settings and specialists and that patients are active participants in their own care. The National Committee for Quality Assurance (NCQA) is a nonprofit organization that certifies a practice as a medical home.
Regardless of whether one accepts all of these potential wide-ranging benefits, the process of becoming a patient-centered medical home can help to transform your practice and provide benefits to patients and staff alike.4,5
This review outlines the background of the patient-centered medical home and details some of the building blocks needed to get started on the NCQA certification process. It also describes the process of choosing the three required and clinically important conditions geared to an older patient population. We then describe the “must-pass” standards in detail, highlight specific geriatric issues, and outline the final submission process.
WHY EXTEND THE MEDICAL HOME CONCEPT TO GERIATRICS?
Although this concept began in pediatrics, it is also well suited for geriatrics. Its features include many that have long been the mainstay of geriatric care: whole-person orientation; partnerships between providers, patients, and families; coordinated and integrated care; enhanced access; a focus on quality; and a focus on management of chronic diseases.2
Traditionally, the management of chronic disease has focused on diseases such as diabetes and congestive heart failure. These diseases have evidence-based interventions, available metrics, and known benefits for both cost and patient outcomes.
However, many of these measures of quality were derived from studies of middle-aged patients with few comorbidities, and they do not necessarily apply to the geriatric population. Moreover, these studies generally do not address functional status, the time frame for expected benefit vs projected life expectancy, the risk-benefit ratio related to managing these conditions, or the patient’s own values and goals.
Therefore, “quality-care” interventions that work well for younger adults may actually harm frail elderly patients.6 An important aspect of building a geriatric medical home is making sure that the changes you implement in care and quality improvement will actually benefit your patients.
WHY WORK TOWARD CERTIFICATION?
In reviewing all the steps involved and the tremendous work required for a successful geriatric medical home, it is worth asking the question: Why work toward NCQA patient-centered medical home certification?
In the end, the goal of undertaking this project is to provide patient care in a way that is comprehensive and efficient. This is the same goal we have always strived for in geriatrics, but now we have an opportunity to measure it and to receive recognition for our work.
In the process of preparing for this application, the practice will have the opportunity to reexamine many of its processes of care, to discover deficits, and to address them. This is something that should be done continuously on some level in any good office practice on a regular basis; the patient-centered medical home application just intensifies the process.
Taking into account the needs of your practice’s geriatric population is a critical component of how one structures the patient-centered medical home. The need to take into account the frail elderly population with limited life expectancy and the lack of evidenced-based data in some areas changes how we manage many chronic illnesses. Geriatrics should take the lead in creating appropriate quality measures for this patient population. Incorporating these concepts into the medical home model is the right way to create a geriatric medical home and helps to lend validity to this concept to insurers and national organizations.
GETTING STARTED
Before getting started, it is important to have adequate support systems in place.
Go electronic. Although the NCQA provides chart-audit tools to facilitate the examination of patient subsets, it is extremely difficult to obtain medical home certification without an electronic health record system. You need to be able to collect and analyze data on your patients, their outcomes, their satisfaction, and other variables important to the practice’s patient population. It is also critical to have personnel with good computer skills, to have administrative support, and to have adequate staffing to support the processes to be put in place.
Talk to major health insurance providers in your area to see if they are interested in supporting your practice. Insurers have a vested interest in their members’ care, and they may have resources to assist with the medical home application.
Learn more. The NCQA provides seminars, online programs (www.ncqa.org/tabid/631/default.aspx), and full-length conferences. These courses provide real examples of documentation that demonstrated compliance with the standards as well as examples of documentation that failed. Learning how to create detailed documentation for the NCQA elements is important.
A good overall resource is the free user’s guide that is available from NCQA. This publication contains step-by-step screen shots to assist in navigating the survey tool, linking documents, and submitting the final survey. Several other organizations have online resources to assist with this process, including the American College of Physicians’ Medical Home Builder (www.acponline.org/running_practice/pcmh/help.htm).7
Gather your documents. The application can be ordered at www.ncqa.org. You can also apply online, and users must purchase a license for the Web application. Final submission of an application involves the following items:
- A completed business associates agreement and the patient-centered medical home recognition program agreement
- A practice profile of all physicians
- The online application form
- The application fee, which ranges from $500 to $4,000, based on the number of physicians in the practice.
Get everyone on board. Most important at this juncture is getting “buy-in.” Studies have shown that becoming a patient-centered medical home requires transformation of the entire practice, including physicians and staff. Shared leadership and protected group reflection time are also helpful.8
In embarking on this journey, the practice should set goals and a realistic time line with an understanding that this is a long and laborious process.
The reward of this major undertaking is the opportunity to examine every aspect of how your practice delivers care and to make meaningful improvements where needed. Practices should not make the mistake of just trying to meet the standards without actually improving quality.
