THE AMERICAN PUBLIC Health Association (APHA) was founded in 1872 with the overarching goal of improving the nation's health through public education and advocacy for the adoption of scientific advances relevant to public health by the US Government. Today, nearly 150 years since its founding, APHA's efforts and accomplishments in promoting wellness, disease prevention, and influencing federal policies to achieve health equity are focused on its current vision to “create the healthiest nation in one generation.”1 To that end, APHA has identified 3 predominant policy priorities: rebuilding the public health infrastructure, ensuring access to care, and reducing health disparities. In 2010, APHA endorsed the Patient-Centered Medical Home (PCMH) model of health care delivery as instrumental in meeting these goals.2
The “medical home” model was first introduced in 1967 by the American Academy of Pediatrics with the goal of centralizing pediatric medical records, especially those of special needs children. By the year 2000, the purpose and definition of the medical home were expanded to include accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.3 In 2007, the 7 characteristics for PCMH recognition endorsed by the major primary care physician associations were published as the Joint Principles of PCMH.4 By then, the PCMH definition had been further expanded to include patient self-management for chronic conditions, following evidence-based practices and procedures, expanded use of electronic medical records, and facilitating access to, and integrating of, specialty care.5
Today, there are 3 main accreditation bodies that focus on assessing a practice's effective transformation and operation as a PCMH: Accreditation Association for Ambulatory Health Care (AAAHC), National Committee for Quality Assurance (NCQA), and The Joint Commission which “accredits and certifies nearly 21000 health care organizations and programs in the United States.”6 Each organization's certification process identifies PCMH competencies, grouped into a set of standards, and criteria for assessing those competencies that its PCMH recognition would certify. Although there is overlap, there are also differences in measurement criteria.
The objective of this review is to gather evidence from academic and professional literature on how achieving accreditation as a PCMH advances the 3 public health goals set by the APHA for increasing access to care, reducing health disparities, and better integrating health care with the public health systems. By mapping accreditation bodies' PCMH recognition standard categories and performance measures to the APHA goals, this review provides further context and rationale for the importance of achieving each measurement criterion on the checklists while identifying additional practical opportunities to address the APHA goals in each standard category.
A CONCEPTUAL MAP OF APHA'S PUBLIC HEALTH PRIORITIES
American Public Health Association's vision of creating the healthiest nation in one generation demands a road map establishing priorities and milestones for achieving those priorities. The critical success factors on the road to achieve the overarching goal of APHA include promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity.7 The Ottawa Charter for Health Promotion8 defines health promotion as a process for enabling people to increase their control over their health and directs policy makers at all levels to accept accountability for the health consequences of their decisions. The importance of efforts to address the risk factors and root causes of mortality and disability from diseases and injuries through public health strategies “using the full range of policies, interventions, and technologies in our arsenal of knowledge” is strongly advocated in the Global Burden of Disease study.9 The need to overcome obstacles to achieving health equity, such as high costs and inadequate insurance10 and disproportionate lack of access in communities to primary care and sustained treatment,11,12 has also become widely accepted.
The APHA public health priorities for realizing the above critical success factors are depicted in the conceptual map developed in Figure 1 and consist of rebuilding public health infrastructure, ensuring access to care, and reducing health disparities.7 The critical role of “ensuring access to care” is markedly noticeable as it directly influences all 4 critical success factors to achieve the goal of a nation of healthy people. According to Murage et al,13 those in the population who require the most access to care, those with chronic conditions, elderly, and disabled, are generally the ones facing the greatest barriers. Patient access includes factors that affect a patient's ability to get the right care, at the right time, and in the right place. Access encompasses insurance coverage, geographic availability, health services and medication ranging from preventive to rehabilitative, and timeliness of care.14 Socioeconomic status is directly linked to health status and access to care, and those lower in socioeconomic status generally live in poorer neighborhoods and longer distances from health services and are often less able to receive timely and preventive care.15 Not surprisingly, states with expansion of Medicaid eligibility experienced reduced mortality among adults living in the poorer areas of the states.16 Fundamentally, ensuring access to care is necessary to bring about patient access needed for realization of the policies and efforts to achieve health equity. In turn, rebuilding the public health infrastructure becomes a prerequisite for ensuring access to care.
REBUILDING PUBLIC HEALTH INFRASTRUCTURE
The National Academy of Medicine report on the Study of the Future of Public Health14 was instrumental in creating an impetus for reexamination of public health infrastructure. Dr Benjamin,17 previous executive director of APHA, identified infrastructure as people “properly trained with the right tools, and a range of resources including linkages and facilities to do the job properly” and recognized the importance of enabling integrated information systems that can communicate with one another. Public health infrastructure has 3 important components: people, information, and processes. The critical success factors of rebuilding public health infrastructure—a capable and qualified workforce, up-to-date data and information systems, and agencies capable of assessing and responding to public health needs—are necessary for preventing and managing disease, as well as for ensuring access to care.7
ENSURING ACCESS TO CARE
The APHA priority for ensuring access to care encompasses patient ability to get the right care, at the right time, and in the right place. The National Academy of Medicine defined access to health care as having “the timely use of personal health services to achieve the best health outcomes” and identified 3 steps in obtaining good access to care:
- gaining entry into the health care system,
- getting access to sites of care where patients can receive needed health services, and
- finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.18
Ensuring access to care can thus be measured by presence or absence of resources that facilitate health care such as insurance coverage, patients' assessments of the ease with which they can gain access such as timeliness of scheduling appointments and geographic accessibility, and ultimately the successful receipt of health services needed. The conceptual map shown in Figure 2 illustrates the components and critical success factors for access to health care.
REDUCING HEALTH DISPARITIES
Achieving health equity by formulating better public health policies and utilizing more informed clinical practice interventions have targeted social determinants of health (ie, the conditions in which people are born, grow, live, work, and age).19 Fuchs20 pointed out that there are many nuances to be considered in attributing the relative importance of the social determinants to health variations. Indeed, there may be psychosocial pathways linking socioeconomic status to health.21 Nevertheless, incorporating social determinants of health in routine clinical practice can make a positive impact on reducing health disparities as Andermann22 identified the following proactive strategies that can be taken at different levels:
- ● Provider-patient interaction-level intervention
- ○ Asking patients about social challenges in a sensitive and caring way
- ○ Following a “social diagnosis” with “social prescribing” that involves connecting patients with various support resources within and beyond the health system
- ● Practice-level intervention
- ○ Improving access and quality of care for hard-to-reach patient groups
- ○ Integrating patient social support navigators/facilitators into the primary care team
- ● Community-level intervention
- ○ Partnerships with community groups, public health, and local leaders
- ○ Using clinical experience and research evidence to advocate for social change
- ○ Getting involved in community needs assessment and health planning
- ○ Community engagement, empowerment and changing social norms.22
The World Health Organization's 2008 call for action on the social determinants of health to close the health gap in one generation emphasized addressing the political, social, and economic forces that shape the circumstances in which people are born, grow, live, work, and age.23 This emphasis is shared by other US health advocacy groups, for example, National Prevention Council,24 National Partnership for Action to End Health Disparities,25 and Healthy People 2020.7 Using underlying factors identified in Healthy People 2020 for 4 areas of social determinants of health, Figure 3 depicts the critical success for reducing health disparities as improving economic stability, education, social and community responsibility, and neighborhood environment.
ACCREDITATION AND REBUILDING PUBLIC HEALTH INFRASTRUCTURE
Rebuilding public health infrastructure is necessary for effective support of ensuring access to care, which, in turn, is needed for reducing health disparities. The 3 components of public health infrastructure, that is, competent health professionals, up-to-date integrated information systems, and public health departments that effectively assess community health needs, plan interventions, implement those plans, evaluate progress, and take corrective actions when needed, provide the foundation for improving public health. It is, therefore, not surprising that accreditation of public health agencies is regarded as an important priority for increasing visibility and accountability of the role of public health.26 Novick27 regards accreditation as a transformative step forward. Indeed, in a 2016 survey of 52 departments accredited by the Public Health Accreditation Board, Kronstadt et al,28 reported general agreement that accreditation has
- stimulated quality and performance improvement opportunities within the health department,
- prompted the health department to use information from the quality improvement processes to inform decisions,
- allowed the health department to better identify strengths and weaknesses,
- helped the health department document the capacity to deliver the 3 core functions of public health (ie, assessment, policy development, and assurance) and the 10 essential public health services, and
- stimulated greater accountability and transparency within the health department.28
The national public health standards, which include the 10 essential public health services, do not prescribe exactly how a department should meet the standards. Instead, the measures describe the type of activities a health department should do including collaboration with others to facilitate serving the population health needs of the community. As pointed out by the Public Health Accreditation Board,26 “Accreditation provides a framework for a health department to identify performance improvement opportunities, to improve management, develop leadership, and improve relationships with the community. The process is one that will challenge the health department to think about what business it does and how it does business.” Figure 4 depicts the role of accreditation of public health agencies in influencing the critical success factors for rebuilding public health infrastructure.
THE ROLE OF PCMH RECOGNITION IN ADDRESSING APHA'S PUBLIC HEALTH PRIORITIES
The Joint Principles of PCMH endorsed by the major primary care physician associations describes the following 7 characteristics for PCMH recognition: physician-directed medical practice, personal physician for each patient, whole-person orientation, coordinated care that is integrated across all elements of the health care system and the patient's community, enhanced access to care, continuous quality improvements in patient-centered services demonstrated by voluntary accreditation, and a payment structure that appropriately rewards the added value that PCMH brings to patients.4 The main reason for PCMH recognition/accreditation is to establish a uniform level of practice, but the incentives for a practice to go through voluntary accreditation grow from recognition of high performance and quality improvement, to accountability to the public and governing bodies, to enhanced access to resources for performance improvement, to participation in a learning community dedicated to excellent health outcomes, and to improvement of public health in the United States.29
Fundamentally, the role of PCMH accreditation is similar to the accreditation of public health agencies to influence the development of a capable and qualified workforce, up-to-date data and information systems, and processes capable of assessing and responding to the health needs of the population served, all of which combine as critical success factors to contribute to APHA's public health priorities as illustrated in Figure 5. Patient-Centered Medical Home accreditation processes define standards/competencies and measures that evaluate the 3 critical success factors, and the equivalency of the approaches may be established by their coverage of the 7 principles for PCMH recognition.
In 2011, an updated version of the 2007 Joint Principles of PCMH was released that called for 13 guidelines that all PCMH recognition and accreditation programs should follow.30 The guidelines ranged from incorporating the joint principles of PCMH, to allowing for recognition of innovative ideas and best practices, to ensuring transparency in accreditation program structure and scoring, to conducting random site visits to audit a percentage of implemented practices.
In 2014, Medical Group Management Association published a comparison of 4 national programs for PCMH accreditation in meeting the 13 guidelines.31 The programs considered included AAAHC 2011 Medical Home Standards, Joint Commission Primary Care Medical Home 2011 and 2014 Standards and Elements of Performance, and NCQA PCMH 2011 and Proposed 2014 Standards. Medical Group Management Association's review concluded that NCQA is in full compliance with the intent of each guideline, whereas AAAHC and Joint Commission are fully compliant except for the guideline requiring accreditation programs to align their standards with meaningful use requirements outlined by the National Coordinator for Health Information Technology. It is important to note that while the Medical Group Management Association review acknowledges that none of the 4 national programs directly addresses the payment structure principle for PCMH, it accepts the inference made by the programs that their standards provide the basis for enhanced payments, thereby fulfilling the intent of the principle.
Given the role of PCMH accreditation in addressing APHA's public health priorities as depicted in Figure 5, it is appropriate to classify each measure used by a PCMH accreditation program in light of those priorities. Table 1 presents such a classification for NCQA's PCMH 2017 measures that are described in Appendix A. Measures (from any NCQA competency area) that evaluate a practice's efforts with electronic health records, documentation, information gathering, tracking, and exchange are classified as addressing the public health priority for up-to-date data and integrated information systems. Measures that focus on evaluating a practice's formal procedures, processes, assessments, evaluations, organizational regulations, and working with other organizations are classified as addressing the public health priority for developing practices capable of assessing and responding to public health needs. Finally, measures that emphasize individual education and experience, judgments, interpersonal relationship skills, and effective patient and community interactions are classified as addressing the public health priority for building a capable and qualified workforce.
A similar classification table is constructed for AAAHC's Medical Home On-Site Certification 2013 and Joint Commission's Primary Care Medical Home Certification Option 2016 accreditation standards in Appendix B and Appendix C, respectively. However, Table 2 provides a consolidated view of the measures used by each program classified by APHA's public health priorities and categorized by the Joint Principles of PCMH.
DISCUSSION AND SUMMARY
Patient-Centered Medical Home Accreditation is important because it helps a primary care practice meet or exceed minimum standards of quality. Having specific, measurable, attainable, and realistic standards is, of course, necessary for the cost-effective transformation of a practice in becoming accredited and for sustaining accreditation. It is indeed quite fortunate that PCMH accreditation has been guided from the outset by the framework formulated by the Joint Principles of PCMH.30 And, it is a testament to the value placed on delivering care based on the PCMH model that in 2011 the primary care societies endorsed guidelines for PCMH accreditation programs.
As shown in Table 2, all 3 PCMH recognition programs considered in this review directly address the Joint Principles except for the “payment structure” principle. This agrees with the review of the earlier versions of the 3 accreditation programs in 2014 that also showed the programs to be otherwise in full compliance with the 13 guidelines.31 The payment structure called for in the Joint Principles is outside the control of the practice being accredited and requires employers and public and private payers to build unique reimbursement strategies such as pay for performance, care coordination payments, risk-adjusted fee for service, and other physician incentive programs.32
Multistakeholder collaborations similar to the ones pilot tested in Colorado, Ohio, and New Hampshire33 are needed to address the cost of transforming a physician practice into a medical home in order to bring about the added value of PCMH model for patient care without adversely impacting health care costs. Pennsylvania's 2008-2011 Chronic Care Initiative demonstrated that with the state taking the leadership role, financially supporting practice transformations to PCMH and holding them accountable to quality metrics, “substantial cost savings and identifiable changes in patterns of health care utilization” primarily through reduced hospitalization costs were realized.34 Similarly, integrated health care organizations, such as Geisinger Health System in Pennsylvania, have demonstrated that it is possible to reduce hospital admissions and save total medical costs by implementing a PCMH model of care that includes enhanced access to primary and specialty care supported with information technology.35 Geisinger is both an insurer and a health care delivery system positioned well to reward enhanced care delivery through PCMH payments. A similar initiative by medical insurers, Medicare, and Medicaid had to wait for the Affordable Care Act (ACA) to materialize.
In 2014, the Centers for Medicare & Medicaid Services paved the way for growth of PCMH movement by implementing the value-based payment modifier required by the ACA to provide differential payment based on the quality of care furnished, compared with the cost of care, during a performance period as documented via its Physician Quality Reporting System. The ACA also advocates the development of Accountable Care Organizations (ACOs) to manage and coordinate care for beneficiaries. An ACO may include multiple primary care providers, specialists, and hospitals organized as a consortium of providers who agree to work together to change how they receive reimbursement—being rewarded or penalized based on their performance evaluation at regular intervals. Unlike PCMH providers who are only accountable to themselves for additional investments beyond PCMH recognition and reaccreditation, an ACO favors shared investments for improving health care delivery to benefit each member of the consortium.36 Therefore, there are financial reasons for a PCMH-accredited practice to consider joining an ACO. More importantly, however, the ACO's focus on care improvement for an entire patient population depends on the type of care management and coordination that the PCMH model offers, making the ACO with PCMH as a component a necessary implementation model.
In a systematic review of the PCMH literature (published during November 1, 2015, to February 28, 2017), Patient-Centered Primary Care Collaborative concluded that although the PCMH model has positively impacted outcomes in terms of quality, patient experience, cost, and utilization, the improvement has not been uniform, cautioning that “like any form of evolution, meaningful transformation takes time, is dynamic in nature, and displays considerable variations in quality, cost, and utilization outcomes,” and a standard “implementation manual” should not be expected.37 Indeed, “understanding that practice transformation is a long-term process, and programs must be allowed to stabilize and mature before results are evaluated” is one of the lessons learned applied by Blue Cross Blue Shield of Michigan, recognized in the Patient-Centered Primary Care Collaborative report as a best practice PCMH program.37 Given that a decade has passed since the publication of the Joint Principles of PCMH, and a PCMH is now considered by the US Department of Health and Human Services to be an alternative payment model, a PCMH is increasingly attractive not only for the uninsured, but also for patients covered by Medicare and commercial payers such as Blue Cross Blue Shield of Michigan. Thus, it seems appropriate to expect that PCMH recognition programs begin to address the “payment structure” principle in their standard categories and performance measurement criteria.
As depicted in Figures 4 and 5, accreditation of public health departments and PCMH recognition of primary care practices both target development of people, information, and processes. It is not surprising that most of the criteria used in all 3 PCMH accreditation programs analyzed in this review are concerned with established processes. Well-designed processes and well-documented procedures for executing them support quality goals, reduce training costs, empower the workforce, enable delegation, and can ensure consistent results. There are, of course, many factors that influence the design of processes including regulation, economic incentives, access to funding, and quality of the infrastructure (physical and information technology). However, the quality and productivity of human resources can readily separate 2 PCMH practices with similar economic and infrastructural capital.
Fundamentally, any organization needs to ensure that its employees have the right skills for the tasks they undertake, receive appropriate training, feel empowered to point out potential improvements, and are rewarded according to their personal motivations (financial incentives, greater responsibility, flexible hours, better projects, advanced education and skills training, etc). A high-performing organization strives for clarity in specifying an employee's role, work process, and performance expectations. Furthermore, such organizations should make determined efforts to retain skilled and dedicated workers as knowledge and experience drive high performance. Therefore, it is quite appropriate that a practice's workforce management and employee engagement processes be measured as a part of PCMH accreditation. This includes ensuring that staff, especially the clinical team, maintain their relevant credentialing, licensure, and professional certifications.
Table 2 shows that the 3 PCMH accreditation programs included in this review are compliant in having evaluation criteria conducive to the development of a capable and qualified workforce. However, the language of these standards does not necessarily go as far as it should in addressing workforce management and employee practices or focusing on the education, training, and certification of clinical team members to enhance quality of care. For example, none of the 3 accreditation programs specifically requires the practice to have board-certified physicians. The Accreditation Association for Ambulatory Health Care only requires the medical home staff to maintain their qualifications and credentials.38 The standards laid out by the NCQA only state that medical staff should “work at the top of their license and provide effective team-based care,”39 and the Joint Commission only requires that the medical staff have the necessary “educational background and broad-based knowledge and experience necessary to handle most medical and other health care needs of the patients.”40
Emphasizing the necessity of physician involvement in quality improvement, physician certification boards now include requirements for physicians to demonstrate their competency in performance analysis and strategies for improving care.41 Research has also shown that physician board certification is associated with positive clinical outcomes and higher quality of care provided to patients.42,43 Additionally, physician board certification is often a requirement for hospital privileging and acceptance by insurance companies and many health plans,44 making lack of board certification somewhat of an obstacle for a PCMH practice in providing the most effective care continuity management, coordination, and transition.
It is important to recognize that in the same way that the PCMH model of care puts the patient at the center of his or her health care, the PCMH recognition standards should place more emphasis on the workforce as the center of accreditation. After all, it is the workforce, both clinical and operational teams, that are charged with implementing the established processes and data management needs of the practice. Therefore, it is appropriate to expect that PCMH accreditation programs provide more impetus for ongoing staff training and certification by incorporating additional workforce qualification measurement criteria in their checklists.
The journey toward the APHA vision of creating the healthiest nation in one generation has benefited from a variety of interventions including government acts and regulations, public health policy changes, multistakeholder collaborations, innovative ideas and technology, novel reimbursement strategies, and voluntary certifications. In APHA's vision, driven by clear priorities to rebuild the public health infrastructure, to ensure access to care, and to reduce health disparities, PCMH recognition does contribute to developing an essential catalyst for realizing a nation of healthy people—a capable and qualified health care workforce.
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National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) Recognition
NCQA's PCMH 2017 (National Committee for Quality Assurance, 2017) requirements for recognizing a practice's transformation into a medical home identify 6 standard areas to be evaluated:
- Team-Based Care and Practice Organization (TC)
- Knowing and Managing Your Patients (KM)
- Patient-Centered Access and Continuity (AC)
- Care Management and Support (CM)
- Care Coordination and Care Transitions (CC)
- Performance Measurement and Quality Improvement (QI)
Each standard area enumerates a set of competencies to be evaluated by a list of criteria/requirements. The detailed criteria for each standard area are listed in Table A1 below.
Accreditation Association for Ambulatory Health Case (AAAHC) PCMH Recognition
AAAHC's Medical Home On-Site Certification (Accreditation Association for Ambulatory Health Case, 2013) requirements for recognizing a practice's transformation into a medical home identify 8 standard areas to be evaluated:
- Medical Home Patient Rights, Responsibilities, and Empowerment (MH1)
- Medical Home Patients Governance and Administration (MH2)
- Medical Home Relationship (MH3)
- Medical Home Accessibility (MH4)
- Medical Home Comprehensiveness of Care (MH5)
- Medical Home Continuity of Care (MH6)
- Medical Home Clinical Records and Health Information (MH7)
- Medical Home Quality (MH8)
Each standard area enumerates a set of criteria/requirements to be evaluated. Table B1 presents a classification of AAAHC's certification criteria in light of APHA's public health priorities. The detailed criteria for each standard area are listed in Table B2 below.
Joint Commission's PCMH Recognition
Joint Commission's Primary Care Medical Home Certification Option (The Joint Commission, 2014) requirements for recognizing a practice's transformation into a medical home identify 5 operational characteristics to be evaluated:
- Patient-Centeredness (JC1)
- Comprehensive Care (JC2)
- Coordinated Care (JC3)
- Superb Access to Care (JC4)
- System-Based Approach to Quality and Safety (JC5)
Each standard area enumerates a set of criteria/requirements to be evaluated. Table C1 presents a classification of Joint Commission's certification criteria in light of APHA's public health priorities. The detailed criteria for each standard area are listed in Table C2 below.