Article Figures & Data
Tables
- Table 1. Members of Oregon's Patient-Centered Primary Care Home (PCPCH) Advisory Committee
Committee Member Background Chair Former President: Regence Blue Cross and Blue Shield of Oregon, Internist Vice-Chair County Health Department Director with experience integrating mental and physical health services Members Medical Director: rural Medicaid MCO, family physician Benefits manager for a large employer Executive Director: Oregon Primary Care Association Vice-President: Oregon Pediatric Society, pediatrician Executive Director: Oregon Nurses Association, RN Community advocate, rural Oregon Medical Director: urban Medicaid MCO, lead sponsor of an ongoing medical home demonstration project, internist Rural family physician Quality Improvement Director: Peace Health Medical Group, faculty at Institute for Patient- and Family-Centered Care Senior Medical Director for Primary Care: Legacy Health, participant in an ongoing medical home demonstration project, internist President: Oregon Academy of Family Physicians, family physician Director of Community Partnerships at an urban safety net clinic, RN Clinical Quality Representative: Kaiser Permanente, family physician Ex-Officio Members Content expert in care coordination, advanced primary care models, informatics and research, internist Content expert in practice transformation, internist Content expert in mental health and health policy, psychiatrist Content expert in primary care, continuity of care and research, family physician Director of Health Care Purchasing: Oregon Health Authority Staff: Addictions and Mental Health Division, Oregon Department of Human Services Staff Administrator: OHPR, family physician Health Policy Development Director: OHPR Health Policy Fellow: OHPR, family physician MCO, managed care organization; OHPR, Oregon Health Policy and Research; RN, registered nurse.
- Table 2. Overview of Core Attributes, Standards and Measures of Oregon's Patient-Centered Primary Care Home Model
Core Attributes Standards Measures Access to care: be there when we need you -
In-person access
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Telephone and electronic access
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Administrative access
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Appointment access
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After-hours appointments
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Telephone advice
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Electronic access
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Prescription refills
Accountability: take responsibility for making sure we receive the best possible health care -
Performance improvement
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Cost and utilization
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Performance improvement
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Clinical quality improvement
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Public reporting
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Ambulatory sensitive utilization
Comprehensive whole person care: provide or help us get the health care, information, and services we need Scope of services -
Preventive services
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Medical services
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Mental health and substance abuse services
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Health risk behavior assessment and intervention
Continuity: be our partner over time in caring for us -
Provider continuity
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Information continuity
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Geographic continuity
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Personal clinician assignment
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Personal clinician continuity
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Organization of clinical information
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Clinical information exchange
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Specialized care settings (hospital)
Coordination and integration: help us navigate the health care system to get the care we need in a safe and timely way -
Data management
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Care coordination
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Care planning
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Population data management
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Electronic health record
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Care coordination
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Test and result tracking
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Referral and specialty care coordination
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Comprehensive care planning 7. End of life planning
Person and family centered care: recognize that we are the most important part of the care team and that we are ultimately responsible for our overall health and wellness -
Communication
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Education and self-management support
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Experience of care
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Communication of roles and responsibilities
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Interpreter services
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Education and self-management support
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Patient experience survey
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- Table 3. Sample Patient-Centered Primary Care Home (PCPCH) Measures: Access to Care (Be There When We Need You)
• Make it easy for us to get care and advice for us and our family members. • Provide flexible, responsive options for us to get care in a timely way. Standard Description Measure Description In-person access -
Make sure we can quickly and easily get an appointment with someone who knows us and our family.
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Ensure that office visits are well-organized and run on time.
1. In-person access -
PCPCH tracks and improves in-person access to care and patient satisfaction with in-person access to care.
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Basic: PCPCH tracks and reports a standard measure of in-person access to care.
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Intermediate: PCPCH sets a specific goal for improving an in-person access measure and demonstrates improvement.
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Advanced: PCPCH meets a benchmark or demonstrates improvement in the percentage of patients reporting high satisfaction with access to in-person care on a patient experience survey.
2. After-hours access -
PCPCH offers access to in-person care outside of traditional business hours.
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Basic: PCPCH offers access to in-person care at least 4 hours weekly outside traditional business hours.
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Additional measure: PCPCH offers access to in-person care ≥8 hours weekly outside traditional business hours.
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- Table 4. Sample Patient-Centered Primary Care Home (PCPCH) Measures: Accountability (Take Responsibility for Making Sure We Receive the Best Possible Health Care)
Standard Description Measure Description Performance improvement Work to improve the care and services you provide and ask us for feedback and ideas about what to improve. 1. Performance improvement PCPCH measures its own performance, with an emphasis on preventive services, sets goals, and improves its care over time. Publically report information about the safety, quality and cost of the care you provide. Basic: PCPCH tracks at least 3 performance indicators, one of which is an indicator of a preventive service, and reports goals for improvement. Show us what you are doing to ensure we will get the right care while avoiding unnecessary care. Intermediate: PCPCH demonstrates improvement towards its reported goals on at least 3 performance indicators, one of which is an indicator of a preventive service. Involve us in helping to decide areas for improvement. 2. Clinical quality improvement PCPCH improves clinical quality indicators,* with an emphasis on indicators of preventive services, in its patient population. Advanced: PCPCH demonstrates improvement in a certain number of clinical quality indicators. PCPCHs achieving a benchmark level of performance on a given indicator would be required to maintain excellent performance, but not demonstrate continued improvement. 3. Public reporting PCPCH participates in a program of voluntary public reporting of practice-level clinical quality (eg, reporting of performance indicators to a health plan, Medicare or Medicaid, the state, or the Oregon Quality Corporation). Intermediate: PCPCH publically reports practice-level clinical quality indicators to an external entity. -
↵* PCPCHs should have the ability to select clinical quality indicators most relevant to their patient population from a preestablished statewide set of nationally accepted quality measures.
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