Millennium Collaborative Care Helping WNY Primary Care Attain PCMH Gold Standard; Driving Clinical Integration


TRANSFORMATION TEAM: Christina Brooks, Practice Transformation Specialist; Jillian Barone-Greenbaum, Patient-Centered Medical Home Certified Content Expert™ and Director of Ambulatory Care Transformation and Provider Engagement; Laura Kennedy, Practice Transformation Specialist; not pictured – Amy Pease (contract) Practice Transformation Specialist      

Millennium Collaborative Care is helping primary practices across Western New York attain Patient-Centered Medical Home (PCMH) 2014 National Committee Quality Assurance (NCQA) Recognition – the Gold Standard for practice transformation.


“Our team is fully engaged and is actively reaching out to primary care practices across the eight counties of Western New York,” said Michele Mercer, RN, MSHA, Chief Clinical Integration Officer. “PCMH enables primary care offices to build structure around their patients from a population health perspective, and in the process, achieve clinical integration.”

The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults by facilitating partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.

The PCMH model can create greater value for patients, providers and payers. As patients are given better access to coordinated care, many factors that drive up costs are impacted significantly including the increase of preventive services; improved immunization rates, decline in emergency department visits and in-patient hospitalizations, and overall decrease of health care costs.

Millennium Team Provides Comprehensive PCMH Support for Primary Care Partners

“The Practice Transformation Team at Millennium believes that working alongside our primary care partners develops strong engagement in all DSRIP deliverables, including Patient Centered Medical Home Recognition,” said Jillian Barone-Greenbaum, Patient-Centered Medical Home Certified Content Expert™ and Director of Ambulatory Care Transformation and Provider Engagement.

According to Jillian, the Millennium team has formally partnered with approximately 30 primary care practices, some with multiple sites, to implement Patient Centered Medical Home and other relevant DSRIP projects.

Since the launch of its practice transformation engagement model in April 2016, Millennium has supported up to 14 practices with Patient Centered Medical Home Recognition at any given time. This support is delivered in many different modalities including regular on-site meetings, staff training, facilitating the application process, ad hoc documentation review, and general Q & A support.

Practices are also provided a robust set of tools to assist with the Recognition process, which include project plans, document templates, and Electronic Medical Records (EMR) support.

As a result of these collaborative efforts, three practices have currently achieved 2014 PCMH Level 3 Recognition, and one is awaiting application results.

They include:






Several more practices will be submitting their PCMH applications by the end of Q1 2017. All practices supported by Millennium Practice Transformation staff are well positioned to complete 2014 Patient Centered Medical Home Recognition by the end of 2017, well ahead of the NYS DSRIP deadline.

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ECMC Family Health Center Earns NCQA “Patient-Centered Medical Home Recognition”

Most recently, Millennium Lead Entity the Erie County Medical Center Family Health Center achieved recognition status for “Patient-Centered Medical Home™ (PCMH™), Recognized–Level 3.”* The effective dates of this Recognition began Nov. 18, 2016 and expire Nov. 18, 2019.


thomas-j-quatroche-jr-phd-presidentceo-ecmc-corpncqalogo3“This is yet another important recognition from a national organization of the high quality care and services our caregivers provide to the citizens of Western New York, “ said ECMCC President and CEO Thomas J. Quatroche Jr., Ph.D.

“As ECMC continues to be a leader in transforming healthcare in Western New York with our partners at the University at Buffalo, the Patient–Centered Medical Home effort demonstrates that we are on the forefront of bringing the right care at the right place at the right time to the patients of our community to improve the health of the community.”

“The NCQA Patient-Centered Medical Home is a model of 21st century primary care that combines access, teamwork and technology to deliver quality care and improve health,” said NCQA President Margaret E. O’Kane. “NCQA’s PCMH 2014 Recognition shows that the ECMC Family Health Center has tools, systems and resources to provide patients with the right care at the right time.”

ECMC’s Family Health Center in partnership with UB Family Medicine offers access to a diverse group of university physicians for primary care and family medicine. Here, families—including children, adults, and seniors—have easy access to a variety of physicians, including family physicians, pediatricians, and geriatric specialists for senior care.

The ECMC Family Health Center offers an on-site lab facility, as well as flexible scheduling, including evening and weekend appointments. ECMC doctors are on call 24 hours a day, and patients can also always speak to a nurse by phone during business hours to discuss any health questions and concerns.

The Patient-Centered Medical Home program reflects the input of the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and American Osteopathic Association (AOA) and others in extension of the Physician Practice Connections Program. It was developed to assess whether physician practices are functioning as medical homes and recognize them for these efforts. The Patient-Centered Medical Home standards emphasize the use of systematic, patient-centered, coordinated care that supports access, communication and patient involvement.

ABOUT NCQA: NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA is committed to providing health care quality information for consumers, purchasers, health care providers and researchers. NCQA recognizes the vital role clinicians play in advancing quality. The Recognition Programs assess whether clinicians and practices support the delivery of high-quality care. The Recognition Programs are built on evidence-based, nationally recognized clinical standards of care. The official NCQA directory of Recognized Clinicians can be accessed at

*Patient-Centered Medical Home™ (PCMH™) is a trademark of the National Committee for Quality Assurance.


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