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The PCMH Portal

What is a Patient-Centered Medical Home?

A patient-centered medical home (PCMH) is a more effective and efficient model of health care delivery. This new model produces better care and lower costs. In a patient-centered medical home:

  • Patients have a relationship with a personal physician.
  • A practice-based care team takes collective responsibility for the patient's ongoing care.
  • Care team is responsible for providing and arranging all the patient's health care needs.
  • Patients can expect care that is coordinated across care settings and disciplines.
  • Quality is measured and improved as part of daily work flow.
  • Patients experience enhanced access and communication.
  • Practice uses EHRs, registries, and other clinical support systems.

For a very good overview of the Patient-Centered Medical Home, please visit http://www.medicalhomeforall.com.

To download a copy of the AAFP's Patient-Centered Medical Home checklist, click here.

PCMH Model at work in North Carolina:

Community Care of North Carolina (CCNC)

CCNC is a demonstration program that began in July 1998 and aims to build upon North Carolinas' Primary Care Case Management Program - Carolina Access - by working with community providers to better manage the enrolled Medicaid population.

CCNC is designed to bring together providers to cooperatively plan for meeting patient needs and to strengthen the community health care delivery infrastructure. Providers are expected to take responsibility for managing the care of an enrolled population, to provide preventive services and to develop processes by which at-risk patients can be identified and their care managed before high cost interventions are necessary.

Currently, CCNC provides care to more than 750,000 Medicaid recipients in the state, making the program the largest payer in North Carolina. The program relies heavily on medical homes, population health management, community-based networks and case-management services to deliver care.

The CCNC program is distinguished by the following features: Partnership, a Population Health Management Approach, and Accountability. For more information on CCNC, please visit www.communitycarenc.com.

Improving Performance in Practice (IPIP)

IPIP is a state-based, nationally led quality improvement initiative funded in large part by the Robert Wood Johnson Foundation. Its origins are in collaboration among the primary care specialty societies to help physicians improve care in the office practice setting. A key feature of IPIP is the use of quality improvement coaches (QICs) who go into physicians' offices and work closely with the entire practice team on improvement efforts.

QICs focus on 5 key areas that help practices provide better care for patients with chronic conditions:

  1. Use a Registry to identify patients with diabetes/asthma prior to the visit
  2. Use a condition-specific decision support tool (e.g., a visit planner)
  3. Create a customized flow diagram and protocols to standardize the care process:
    • Use nursing standing orders to increase reliable execution
    • Use a standard protocol
    • Assign specific care team roles (who does what in the protocol)
  4. Conduct frequent monitoring of protocol use
  5. Educate patients in self-management and support their efforts

For more information on IPIP, please contact Ann Lefebvre at ann.lefebvre@med.unc.edu or phone: 919-412-4220.

646 Waiver

North Carolina officials have asked the federal government to approve a plan to move the state's higher-cost Medicare patients into a primary care Medicaid management program that has saved the state millions of dollars during the past few years.

Officials submitted what is known as a 646 waiver to CMS earlier this year, asking the agency to approve a five-year demonstration project that would put the state's high-risk Medicare patients and dual eligibles (i.e., patients qualifying for both Medicaid and Medicare) into a primary care program known as Community Care of North Carolina, or CCNC (see above for more information on CCNC).

  • 2013 Mid-Summer Digest
    June 30 - July 6- Myrtle Beach, SC
  • 2013 Sports Symposium
    July 5-6 Myrtle Beach, SC
  • 2013 Winter Family Physicians Weekend
    Dec. 5-8 - Asheville, NC
Click for 2013 Exhibiting Info

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