The PCMH, also called patient-centered primary medical homes, has five attributes:
- Comprehensive care: PCMH is accountable for meeting the large majority of each patient’s physical and mental healthcare needs, including prevention and wellness, acute care and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators and care coordinators;
- Patient centered: The PCMH focuses on the whole person, understanding and respecting each patient’s unique needs, culture, values and preferences, and supports patients in learning to manage and organize their own care;
- Coordinated care: The PCMH coordinates care across specialty care, hospitals, home healthcare, community and transition-of-care support services;
- Accessible services: The PCMH delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team and alternative methods of communication, such as e-mail and telephone care; and
- Quality and safety: The PCMH demonstrates a commitment to quality and quality improvement via ongoing engagement in such activities as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management.
For specialty physicians, the National Committee for Quality Assurance (NCQA) now has recognition requirements to become a PCSP:
- Track and coordinate referrals with other specialists and PCPs to coordinate testing and care of shared patients;
- Provide access and communication via timely appointments, telephone and secure electronic messages during and after office hours, and training team members to be patient centered;
- Identify and coordinate patient populations by capturing key clinical and administrative data to facilitate reporting on specific populations, using evidence-based tools to manage care for those populations and providing follow-up when care is needed;
- Create and manage a patient-centered care plan that includes patients’ medications and referrals to educational resources and community services;
- Track and coordinate care, such as hospital transitions, lab, imaging and other specialty referrals with other practices from the point of request through receipt and patient notification; and
- Improve performance by measuring clinical processes, outcomes and patient experience, showing improvement over time and demonstrating transparency by sharing data within the practice and with external organizations.
Currently, most rheumatology practices are influenced by the community and healthcare system they are in but do not incorporate such models into their practices. However, the Washington Rheumatology Alliance demonstration project is moving in this direction.
What if you designed & offered a two-month musculoskeletal consultation & care package for patients being considered for surgery or expensive spine procedures?
Increasing Musculoskeletal Population & Costs
In the future, rheumatologists’ value to the system and compensation will likely correlate with the contribution they make to the organization’s overall success. If success is the Triple Aim, then we will need to help optimize patient satisfaction and quality of care, help attain the highest level of musculoskeletal health for the population in question and help reduce the per capita musculoskeletal expenditures.
