Model of Care

Care delivery in the United States is shifting. We are finding better and more innovative ways to coordinate care across the system, engage and empower patients, and manage costly chronic diseases. This shift starts with health information technology (HIT) and meaningful use. An institution that is a meaningful user of HIT can care for its patients with more powerful tools and data than ever before.

Patient Centered Medical Homes

With information at its fingertips, primary care practices can become Patient Centered Medical Homes (PCMH). The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. 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. The U.S. Health Resources and Services Administration’s Patient-Centered Medical Health Home (PCMHH) Initiative encourages community health centers to undertake and document the practice changes that will enable them to gain recognition from the National Committee for Quality Assurance (NCQA) through their PCMH program. To promote quality improvement, the PCMHH Initiative provides access to survey-related education, training, and technical assistance resources that highlight the benefits of seeking recognition and common barriers to success. The fee for gaining NCQA PCMH recognition is waived for health centers that participate in HRSA’s PCMHH Initiative.

For additional information, visit our program page on Improving Quality of Care.

Clinical Integration Networks

There are a variety of options to improve care and lower costs, most of which are based upon the foundation of the Patient Centered Medical Home. One example, a Clinical Integration Network (CIN), is a framework for otherwise competing physicians to collaborate in an effort to reduce costs and provide improved health care. There are four commonly cited indicators of a CIN:

    1. They exchange health and other information electronically;
    2. The providers develop and adhere to clinical protocols to direct care;
    3. There is oversight of all care provided; and
    4. There is an enforcement mechanism to ensure protocol adherence.

In 2012, DCPCA member health center Mary’s Center received nearly $15 million through the Centers for Medicare & Medicaid Services Health Care Innovation Awards. DCPCA is pleased to be partnering with Mary’s Center as they work to implement and test an integrated clinical network to improve care for chronically ill people in the DC area who rely on emergency room (ER) visits for health care. The project will use a District-wide database, care teams, and tele-health to communicate with these patients, develop care plans for them, and personally manage their care as they are gradually transitioned into patient-centered medical homes. The result will be lower cost from reduced dependence on crisis care and ER visits and better health care for people with controllable chronic conditions such as diabetes, hypertension, asthma, and co-occurring mental illness.

Over a three-year period, Mary’s Center will train and hire 44 health care workers to serve as care managers and community-based care coordinators.

These are just examples of how the health care system in DC is changing, and you can look to DCPCA to help lead you on the path towards improved care delivery.

DCPCA’s Policy and Advocacy Goals Remain Focused on:

    1. Efforts to Achieve 100% Health Insurance Coverage Among District Residents;
    2. Efforts to Develop Public-Private Partnerships in Prevention and Health Service Delivery;
    3. Efforts to Facilitate the Development of a Fully Integrated Health System; and
    4. Continue to Build and Strengthen Relationships with Media to Ensure Maximum Coverage.

For more information, read the one-pager about our Policy, Advocacy, and Health Reform efforts, visit Health Care Reform, our Health Equity Blog, or read our Testimony.

For additional information about health reform in the District of Columbia, contact Howard Liebers, MPH, DCPCA’s Director of Policy, at (202) 552-2316.

Copyright ©2004-2015 All Rights Reserved District of Columbia Primary Care Association