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How to Sustain Effective Medical Home Care Coordination

Doctor talking to patient.

The National Committee for Quality Assurance defines a patient-centered medical home (PCMH) as “a model of care that puts patients at the forefront.” The PCMH highlights the importance of care coordination and provides pathways to ensure that the medical neighborhood is tangible to the patients served.  

The tenants of the medical home ask care teams to treat patients for their medical, behavioral and address their social and economic needs to achieve desired outcomes. As one of the 6 concept areas of the PCMH, it is imperative to implement policies, workflows and partnerships that will promote relationships outside of the primary care setting.  

Medical homes are not just care settings but care connectors. Read on to learn: 

  • how to sustain the medical home through effective care coordination; 

  • why practices shouldn’t exclude community-based organizations; and 

  • the key technical components for an effective, sustainable PCMH care coordination model. 

Sustaining your medical home through effective care coordination 

NCQA further defines a PCMH as a way to organize primary care. Care coordination ensures that primary care practices and specialty and behavioral care providers, hospitals, care centers, community-based organizations and other partners effectively share information and manage patient referrals. In other words, it is a team-based sport to close the patient care loop. 

Care coordination spans settings, services and specialists 

Medical homes organize care through information sharing, direct and clear asks, and referral management. This approach spans: 

  • all settings outside of your four walls, e.g., testing facilities, hospitals and urgent care; 

  • all services, ideally integrated, including medical, behavioral and social care; and 

  • all specialists, with referrals managed via informal and formal agreements that standardize and professionalize care. 

These components help achieve the key PCMH care coordination objective: closing the care loop with patients in mind in a manner that is achievable based on the patient’s needs and preferences. It addresses questions like: 

  • How impactful is information sharing if the patient or care partner is not on the same page and doesn’t understand the goals? 

  • How advantageous is referral issuing if the patient can’t access the additional care suggested? 

  • How beneficial is referral management if there is no proper follow-through to impact the patient’s outcomes 


Community-based organizations: Your missing partner 

PCPs and SCPs often overlook community-based organizations as partners. Every medical home involves connections to resources and CBOs that link to patients’ conditions, diagnoses and social needs.  

CBOs connect the dots between patient needs and community resources. They’re as important as specialists in effective care coordination/medical home.  

For example, CBOs can provide certain kinds of social care, including screening patients who live alone and/or have complex needs. They can also determine whether patients need additional mental health, substance use or other social support.  

Practices must treat orders they place to CBOs as they would specialist orders: care must be complete, and the order closed. This allows for effective care coordination to occur and for the medical home to truly be patient centered. Social support and community partners help provide resources and tools that lead to more equitable care.  

3 PCMH technical and sustainability components  

PCMH technical and sustainability components help develop stronger relationships between patients and their clinical care teams. People and processes are at the core of this.  

For instance, PCPs and SCPs use policy-driven workflows and optimized electronic medical records. This helps organize, manage and share information, e.g., referrals, orders and reports, which lead to coordinated, patient-centered care. Effective medical homes must be sustained by: 

1. Maintaining recognition 

To achieve NCQA PCMH recognition, practices must meet criteria within six program concept areas. Annually, practices attest to the continued sustainment of the PCMH and report on selected requirements. The medical home can be audited by NCQA, and it is imperative to maintain the integrity of the entire PCMH at all times.

2. Increasing financial strength

More than 95 organizations offer financial incentives for NCQA PCMH recognition. In addition, according to the latest research on evidence of PCMH effectiveness, “PCMHs are saving money by reducing hospital and emergency department visits, mitigating health disparities and improving patient outcomes.”

3. Participating in value-based care

Care coordination and VBC share a common objective: to minimize cost, confusion and inappropriate care. Being a PCMH can unlock new payment models by streamlining participation in both VBC and NCQA programs.

Reinforcing these principles across care settings, services and providers requires consistency, teamwork, monitoring and training. Ultimately, it's worth the effort, time and patience, as it improves care outcomes, coordination and organization, resulting in high-quality healthcare systems. 

What patients want; what practices need 

The NCQA describes the PCMH medical home as a place where patients want their care to be — a place that exceeds their needs.  

Care coordination is just one component of DataGen’s Medical Practice Consulting. Our comprehensive practice advancement strategies help providers: 

  • meet and sustain NCQA requirements, i.e., achieving effective care coordination in the medical home; 

  • improve cost, quality and use; and  

  • most importantly, improve the patient experience. 

Contact us today to take the guesswork out of practice transformation


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