August 28, 2018

Patient-Centered Medical Home (PCMH) Model

This summer has taught us a lot about Practice Transformation, and more specifically about the Chronic Care and Patient Centered Medical Home models. Our understanding was recently expanded by a presentation from Mike Hindmarsh from Hindsight Healthcare Strategies at the August Leadership Council meeting.  Mike was the Associate Director of Clinical Improvement under the guidance of Ed Wagner, MD, MPH of the MacColl Institute in Seattle, WA.  Along with Dr. Wagner, Mike and his colleagues created the Chronic Care Model – a system redesign strategy to improve the care for chronically ill patients.    For the last 25 years, Mike has directed and advised over 200 clinical improvement efforts offering his expertise in the design and development of dissemination strategies for implementing the Chronic Care Model and the Patient-Centered Medical Home in the United States, Canada, and internationally. Mike said that the future of our healthcare system depends on our ability to improve care for the chronically ill, and in order to meet the needs of today’s chronically ill, primary care has to evolve to be more patient centered.

Fortunately, the PCMH model of care provides the framework to deliver patient centered care, and is the gold standard for care quality as acknowledged by three accrediting agencies, the National Committee for Quality Assurance (NCQA), the Joint Commission, and the Accreditation Association for Ambulatory Health Care (AAAHC).  GCACH has adopted this model for our Demonstration project because it meets the framework needed to provide the care our high-risk patients need to improve.

What makes the care so patient centered?

It is team based. Behavioral health, primary care, chronic care, and social determinants are addressed and coordinated by the primary care team who work at the top of their licenses.

The practice uses evidence based guidelines to support clinical decisions related to mental health issues, chronic diseases, substance use disorder treatments, acute conditions, unhealthy behaviors, well child or adult care and appropriateness of care issues.

It includes the patient as an active participant in their own care. It uses techniques like patient activation and consumer feedback. Continuity of care is continuous, and culturally competent.

It measures results, and knows its patients. Patients are empaneled, risk stratified and proactively managed through knowledge of individual diseases and risk.

In July, the GCACH Practice Transformation Workgroup selected the initial cohort of providers for PCMH efforts. Several of these organizations are already PCMH recognized; Community Health of Central WA, Yakima Neighborhood Health Services, Yakima Valley Farm Workers Clinic, Columbia Basin Associates, Tri-Cities Community Health, and Community Health Association of Spokane (CHAS), all Federally Qualified Health Centers. As such they will be mentors for the region, and be asked to share their experience with their peers. 

GCACH is hosting a dinner for the Provider organizations to kick off the next phase of practice transformation. Beginning in the fall, the Practice Transformation team will begin the assessment process with organizations to establish infrastructure needs, population health management tools, and a communications platform. Actual implementation of the Demonstration with begin in January of 2019, with rolling starts as organizations come on-line and contracts have been signed.

We thank the following organizations that have agreed to embark on this journey with GCACH as the first cohort for 2018:


- Astria Regional

- Astria Sunnyside

- Astria Toppenish 

- Catholic Family Services



- Columbia Health System

- Community Health of Central WA

- Comprehensive Healthcare

- Garfield Hospital

- Kadlec 

- Kittitas Valley Healthcare

- Lourdes Health Network

- Memorial Physicians

- Palouse Medical

- PMH Medical Center

- Providence St. Mary's 

- Pullman Regional 

- Quality Behavioral Health 

- The Student Center

- Tri-Cities Community Health 

- Yakima Neighborhood Health Services

- Yakima Valley Farm Workers