Primary Practices Transforming to Patient-Centered Medical Home (PCMH)

JanetStoecklBy Janet Stoeckl, RN, CNN, Clinical Director

The Ambulatory Services Team is focusing on primary care practice transformation, with a strong focus on patient centered medical home for primary care practices.

Our team is fully engaged and is actively reaching out to primary care practices. We are performing assessments of the status of practices in relationship to meeting DSRIP primary care deliverables; and developing action plans to work with the practices to facilitate their success.

What is PCMH?

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

The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.

NCQAlogo3National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) Recognition is the most widely-used way to transform primary care practices into medical homes.

The National Committee for Quality Assurance is an independent 501 non-profit organization in the United States that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation.

What is the value-add of having a primary care practice transformed to PCMH recognition?

The PCMH model can create greater value for patients, providers and payers. Patients are given better access to care that is coordinated. Because of this, many factors that drive up costs are impacted significantly. These factors include the increase of preventive services, immunization rates improve, emergency department visits and in-patient hospitalizations decline and health care costs decrease

Through the medical home model, primary care practices seek to improve the quality, effectiveness, and efficiency of the care they deliver while responding to each patient’s unique needs and preferences.

No matter where a practice currently falls on the spectrum of PCMH transformation — healthy skepticism, just getting started, in the middle of practice redesign, or implementing advanced concepts — the adoption of PCMH concepts can benefit primary care practices, their patients, and the bottom line.

The Millennium Transformation Team is focusing our efforts on 92 primary care practice sites that have been identified as a safety net provider by New York State or are a non- safety net provider with a high volume of Medicaid/uninsured covered lives.

  • 51 of the 92 sites have had a PCMH, Behavioral Health Integration, Clinical Integration, Data Sharing assessments completed. The purpose of these assessments are to identify the strengths and weakness of the practice and put in place a remediation plan for a successful transformation for that practice.
  • The following practices have attained PCMH 2014 Level National Committee Quality Assurance (NCQA) Recognition- The Gold Standard for practice transformation.
  • Aspire Health Care
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  • Evergreen Health Services of WNY
  • Dr. Haddad – GBUAHN
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  • Dr. Rajiv-General Physician
  • Jericho Road Community Health Center
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  • Barton Street
  • Neighborhood Health Center
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  • Lawn Ave
  • Niagara Street
  • Summit Pediatrics
  • Summit-Pediatrics
  • Lewiston
  • Pine Ave
  • Niagara Falls
  • UB Family Medicine – Jefferson
  • UB-Family-Medicine-300x44

Congratulation to each of these provider sites!


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