Patient-Centered Medical Home Toolkit


   1.  Introduction to PCMH

   2. Definitions of PCMH
        a. Joint Principles of the Patient-Centered Medical Home
        b. Michigan Definition of PCMH

   3. PCMH Validation Programs

A.  NCQA Recognition 
        1. NCQA  Requirement Overview:          2008       2011     
        2. NCQA  PCMH Content and Scoring:   2008       2011
        3. PRISM One Pagers for NCQA Recognition

B.   PGIP Designation (Blue Cross Blue Shield of Michigan)
        1. BCBSM PCMH and PCMH-N Interpretive Guidelines 2012-2013
        2. BCBSM PCMH Summary Document
        3. BCBSM PCMH One-Page Summary   

C.  Crosswalk: Joint Principle Characteristics, NCQA Standards and BCBSM-PGIP Domains
        D.  Other Validation Programs - Joint Commission, AAAHC, URAC



  1Personal Physician - Each patient has an ongoing relationship with a personal physician
        trained to provide first contact, continuous and comprehensive care.

        •   Medical Home is About You. National Partnership for Women and Families.
        •  Patient-Physician Relationship. AMA, AARP.

  2.  Physician Directed Medical Practice the personal physician leads a team of
        individuals at the practice level who collectively take responsibility for the ongoing care
        of patients. 

  3.  Whole Person Orientationthe personal physician is responsible for providing
        for all the patient’s health care needs or taking responsibility for appropriately
        arranging care with other qualified professionals. This includes care for all stages
        of life; acute care; chronic care; preventive services; and end of life care.

        a.  Individual Care Plan- Acute, Preventive, Chronic Illness, End of Life
Personal Action Plan
             Ask Me 3 Poster

        b.  Self-Management Support (See Self Management Support Toolkit for Providers)
            1.  General
                  •    IHI and RWJF  Partnering in Self Management Toolkit
                  •    Stages of Change
             2. Chronic Illness Care
                  Links to education materials for the chronic diseases of focus.
                   •    National Diabetes Education Program
                   •    Michigan Path Chronic Disease Workshops 
                   •    CHCS Asthma education materials for patients
                   •    National Heart, Lung and Blood Institute: Health Information for
                   •    Nation Heart, Lung and Blood Institute: Coronary Artery Disease
                               Educational Links
                   •    National Asthma Education: and Information Program
                   •    IHI: Deliver Reliable, Evidence-Based Care for Congestive Heart Failure
                   •    What is coronary artery disease?     
                   •    American Lung Association COPD Toolkit
               3. Preventive Care
                    •    U.S Preventive Services Task Force. Reviews evidence and makes
                         recommendations regarding preventive care
                    •    Workplace Smoking Cessation Implementation Suggestions 
                    •    Health Care Provider Guide to Free or Reduced Cost Smoking Cessation
                         Medication for Michigan Residents
                    *   American Lung Association: Stop Smoking

  4Care is Coordinated - Care is coordinated and/or integrated across all elements of the
        complex health care system (e.g., subspecialty care, hospitals, home health agencies,
        nursing homes) and the patient’s community (e.g., family, public and private community
        based services). Care is facilitated by registries, information technology, health
        information exchange and other means to assure that patients get the indicated
        care when and where they need and want it in a culturally and linguistically
        appropriate manner.

        a.  Specialist Tracking
        b.  Linkage to Community Services
               •    Michigan Health Go Local. A link to health services in Michigan
               •    211 Information and Referral Search
               •     Oakland County Community Services Agencies
               •    Macomb County Resources List
               •    Wayne County Homepage
               •    Michigan Department of Human Services

        c.  Care Transitions

   5.  Quality and Safety - Quality and safety are hallmarks of the medical home.  click here

         a.  Patient Registry
               IPIP Registry Comparison       
         b.  E Prescribe•    
               Dr. First E-Prescribe Tool Website
               Surescripts: Certification Status of Multiple Products
         c.  Electronic Health Record
         d.   Test Tracking
                KMA: Tracking TestResults Within a Physician Practice
         e.  Performance Reporting

  6 .  Enhanced Acess to Care - Enhanced access to care is available through systems such 
         as open scheduling, expanded hours and new options for communication between
         patients, their personal physician, and practice staff.

        a.  Sample Urgent Care Partnership Form - Select a local urgent care and establish a 

        b. Patient Portal

 7.  Payment Reform - Payment appropriately recognizes the added value provided to
       patients who have a patient-centered medical home. The payment structure should be
       based on the following framework:
click here
       BCBSM-PGIP: T Code Policy for Chronic Illness Care 

8.  Getting to PCMH
       A. Practice Redesign
            Model for Improvement
            Practice Management
            •   American Medical Association: Practice Management Center

     B.  Education/Training/Coaching

     C.   Blue Cross Blue Shield of Michigan PCMH Example Materials


  1. Resources for PCMH Implementation Assistance

Last update Jan 2, 2011