The term “patient-centered medical home” (PCMH) can be confusing because it is not actually a physical place, but a model of care delivery. Harvard Vanguard Medical Associates has been practicing this model of care for many years, well before the “medical home” phrase was coined. Typically, a “medical home” offers patients the following services and attributes:
Over the last five years, Harvard Vanguard has continued on its journey to enhance our model of care delivery and to engage in activities to build our medical home approach within our primary care departments.
In 2011, the Harvard Vanguard pediatrics department applied for and was chosen as one of 13 pediatric practices in Massachusetts to participate in the Children’s Health Insurance Portability Act (CHIPRA) grant led by the National Institute of Children’s Healthcare Quality (NICHQ). Our focus was to improve coordination of care in between medical visits, regardless of whether the child is at home, at school, or participating in a community event.
NICHQ led Harvard Vanguard and 12 other practices in the commonwealth on a 29-month breakthrough series learning collaborative to implement patient-centered medical homes in pediatrics. The participants in this collaborative came together virtually and in person to learn from experts and each other about topics including medical home transformation, improvement science and incorporating parent and family partners into improvement activities.
We chose to pilot the PCMH model the pediatric department at our practice in Chelmsford. We knew taking this on would require a significant amount of staff time and resources, but we were inspired by the vision of improving the lives of our pediatric patients with complex medical issues.
Several key steps in the process included:
What’s unique and different at Harvard Vanguard is that we have taken a very proactive approach to optimize the health and well-being of patients with complex medical and psychosocial needs by integrating complex systems and specializing care to fit the unique need of these patients and their families.
As part of this proactive approach, we created a new position of a care facilitator who is an integrated member of the pediatric department. The role of the care facilitator is to provide assistance with access to care and navigation of the health care system both during and in between medical visits. They identify barriers such as accessing care, integrating healthy behaviors and medication plans, and gaps in basic needs and resources to help patients achieve their goals. The care facilitator serves as a critical link between the patient and patient’s family and the medical care team, hospitals, specialists, school, insurance providers and ancillary services (skilled nursing; occupational, physical and/or speech therapy; durable medical equipment vendors and the Department of Children and Families.) Our goal is to look for opportunities to make a positive impact on the patient’s and family’s experience as well as the quality and cost of their medical care.
A team comprised of a primary care physician, a registered nurse, a care facilitator, a regional nurse case manager and a site social worker meet monthly to review the list of children with complex medical needs in order to optimize and coordinate care. Preparation for this roster review includes outreach by the care facilitator to the parents to identify any goals, gaps or barriers in their child’s care so they can be addressed by the care team.
We were eager to continue to develop and spread the pediatric medical home across all Harvard Vanguard practices so in 2014, the pediatrics department at Harvard Vanguard applied for and was awarded a grant from the Harvard Pilgrim Health Care Quality Grant Program. As a result of this grant, a designated care facilitator has been put in place at our Chelmsford, Quincy and Braintree practices and will be expanding to our Chestnut Hill/West Roxbury practice in the fall of 2015.
The feedback from the families of these patients has been overwhelmingly positive. They are so grateful to have an advocate to help them meet their basic needs such as food and transportation, as well as more complicated tasks such as assistance in navigating the health care system.
In recognition of our overall medical home efforts, Harvard Vanguard joined other Atrius Health affiliates in receiving recognition from the National Committee for Quality Assurance (NCQA). In October of 2014, all Harvard Vanguard Medical Associates practices, including adult medicine, family medicine and pediatrics received recognition from NCQA as a Level 3 Patient-Centered Medical Home 2011 (PCMH 2011) for our model of healthcare delivery that encourages improved quality and enables greater involvement of patients in their own care.