Health Practice Redesign and Patient-Centered Medical Homes

Coordinating care in health practice redesign integrates systems of care that include specialist, hospitals, and both institutional and community-based long term services and supports. The care is ideally centered in advanced primary practices that employ an interdisciplinary team approach. One such model is the patient-centered medical home.

Transforming a primary care practice to a patient-centered medical home model can reduce emergency room visits by up to 70 percent and decrease hospital readmissions by up to 40 percent to achieve vast savings in health care costs, according to a 2012 report from the Patient-Centered Primary Care Collaborative, a broad-based national advocacy organization for the primary care patient-centered medical home model.

Our team helps practices develop measures of progress that can be aggregated and analyzed. We help medical practices adopt an approach to health care that includes all the features of a comprehensive patient-centered medical home model, including the following:

  • Patient- and family-oriented approach
  • Team-based care
  • Coordinated and integrated are
  • Enhanced access to care
  • Focus on quality improvement
  • Evidence-based practices

Our team is also working to integrate behavioral health and medical care both at the care delivery level, by training providers about collaborative practice — and at the policy level, through Medicare–Medicaid integration initiatives.

Expertise to help you establish the medical home model

Through patient-centered medical home projects in Massachusetts and Rhode Island, the Center for Health Policy and Research has developed a range of services to foster transformation and improvement of primary care service delivery.

When you work with our team, you gain the benefit of participating in our learning collaborative, whether through formal sessions or phone consultation. We offer a full range of educational resources:

  • Webinars
  • Presentations
  • Toolkits
  • Online courses

We help practices develop team-based care, new workflows, practice-based clinical care management, and effective use of health information technology. Our experts are also adept at preparing for the NCQA patient-centered medical home certification.

Massachusetts: Public payers and patient-centered medical home

In Massachusetts, more than medical practices have embarked on the journey to become medical homes. All told, these practices care for approximately 178,000 adult and pediatric patients, most of whom are insured by public payers. As part of the Massachusetts Executive Office of Health and Human Services’ Patient-Centered Medical Home Initiative, our staff provided a wide range of assistance: 

  • Development of aims and goals
  • Data collection, review, and reporting
  • Measurement and analysis of performance data
  • Technical assistance support for learning collaboratives, practice facilitation, consultation for NCQA patient-centered medical home recognition, and support for consumer engagement
  • Facilitation and analysis of care coordination and clinical care management implementation

Our mixed-method evaluation focuses on practice transformation, patient experience, provider satisfaction, quality measures, and cost savings.

We are also leading development of clinical delivery design for other integrated care initiatives for the state’s Medicaid program, MassHealth, including MassHealth Primary Care Payment Reform and Health Homes.

Rhode Island: State collaborates with private insurers to create patient-centered medical home

In Rhode Island, our team is assisting with the Chronic Care Sustainability Initiative, a statewide project that aims to transform health care delivery in the state. In response to a directive from the Office of the Health Insurance Commissioner, this initiative is aligning purchasers to develop a medical home model that achieves these goals:

  • Aligns quality improvement and financial incentives among Rhode Island’s health plans, purchasers, and providers
  • Improves care of patients with chronic conditions, in primary care settings
  • Enhances attractiveness and viability of primary care as a specialty in Rhode Island

With Center for Health Policy and Research experts serving as co-directors of the initiative, our team played a key role in the launch of the pilot in 2006 and its subsequent expansion. The program served approximately 10 percent of the state’s residents by the end of 2012. Leaders anticipate that the numbers of patients cared for will double within two years or less.