1. IU Methodist Family Medical Center
and the
Patient-Centered Medical Home Model
Kaitlyn Aiello
John D. Patton
MHA Capstone
April 23, 2011

2. IU Methodist Family Medicine Center
(IUMFMC)
 Largest outpatient site in IU Family Medicine
Department
 Training facility for IU School of Medicine Family
Practice Residents
 Mission: Promote optimal health for individuals, families, and the
global community and provide continuing and comprehensive patient
care and deliver excellence in family medicine through innovative
medical education and practice-based health services research.
 Vision: Provide accessible, cost-effective health care to all individuals
and families through national and international participation in medical
education and research that make a significant difference in the lives of
people.

3. Project Goal
 Examine the operational, financial, and
systems feasibility of the IU Methodist
Family Medical Center achieving
certification as a Patient Centered Medical
Home.

4. Patient-Centered Medical Home
 A health care setting that facilitates
partnerships between individual patients, their
personal physicians, and the patient’s family.

5. Patient-Centered Medical Home

6. Principles of the PCMH
 Personal Physician *
 Physician directed medical practice
– Behavioral Health
– Dental
 Whole Person Orientation
– Acute, chronic, preventive, end of life
 Coordinated Care
– Registries, information technology, health information
exchange
– Culturally competent
– Linguistically appropriate

7. PCMH Standards
 Access and Communication
 Patient Tracking and Registry Functions
 Care Management
 Patient Self-Management Support
 Electronic Prescribing
 Test Tracking
 Referral Tracking
 Performance Reporting and Improvement
 Advanced Electronic Communications

8. Must Pass Elements
 PPC1A – Written standards for patient access and patient
communication
 PPC1B – Use of data to show meeting this standard
 PPC2D – Use of paper or electronic-based charting tools to organize
clinical information
 PPC2E – Use of data to identify important diagnoses and conditions
in practice
 PPC3A – Adoption and implementation of evidence-based guidelines
for three conditions
 PPC4B – Active support of patient self-management
 PPC6A – Tracking system for tests and to identify abnormal results
 PPC7A – Tracking referrals with paper-based or electronic system
 PPC8A – Measurement of clinical and/or service performance
 PPC8C – Performance reporting by physician or across the practice

9. Project Objectives
1. Examine current process in place at IUMFMC
through staff and management interviews to
identify immediate noticeable barriers.
2. Study and analyze NCQA PCMH certification
process and compare to current IUMFMC
practices.
3. Offer recommendations on any PCMH elements
where operational, personnnel, or information
technology gaps exist.

10. PPC-PCMH Scoring
Level of Qualifying Points Must Pass Elements
at 50%
Level 3 75-100 10 of 10
Level 2 50-74 10 of 10
Level 1 25-49 5 of 10
Not Recognized 0-24 <5

11. IUMFMC Gap Analysis
Strategic Current Deficiency Action Plan
Objective Standing
PPC 1 A. 10 of 12 items Email consultations Add emailing
Processes Patient portal capabilities to current
website
PPC 1 B. Email and website 1 A.
Results response times Policy
PPC 2 A. 14 of 18 items Marital Status Upgrade June, 2011
Basic System for Voluntary self-
Managing Patient identified race/ethnicity
Data Email address
Billing codes for
services

12. IUMFMC Gap Analysis
Strategic Current Deficiency Action Plan
Objective Standing
PPC 2 B. 9 of 10 items Status of age- Available if given at
Electronic System appropriate preventive facility.
for Clinical Data services Recommend
(immunizations, requesting
screenings, counseling) information from
patient and scanning
into record.
PPC 3. Currently meets
Care Management or exceeds all
elements
PPC 4 A. 1 of 2 items Identify and display in Language assistance
Documenting the record the is available.
Communication language preference of
Needs the patient and family.

13. IUMFMC Gap Analysis
Strategic Current Deficiency Action Plan
Objective Standing
PPC 4 B. 6 of 7 items Provides educational Provides resources,
Self-Management resources in the language but not documented.
Support or medium that the
patient/family
understands.
PPC 5. Currently meets or
Electronic exceeds all elements
Prescribing
PPC 6 B. 5 of 6 items Retrieve imaging text  IUMFMC already has
Electronic System reports directly from some imaging and lab
for Managing Tests source services available onsite.
Retrieve images directly Recommend an
from the source upgrade to current HIS
Flag duplicate tests with features that
ordered address these missing
Generate alerts for items.
appropriateness of tests
ordered

14. PPC 7 – Referral Tracking
 Must pass element
 Origin of the referral
 Clinical details
 Tracking status
 Administrative details

15. PPC 8 – Electronic Reporting –
External Entities
 Transmit 10 or more nationally approved
performance measures to an external
entity
 Currently produces the reports – however,
they are not transmitted to the public

16. PPC 9 – Availability of Interactive
Website
 Request appointments
 Request referrals
 Request test results
 Request prescription refills
 See elements of their medical record
 Import elements of their medical record
into a personal health recored

17. PPC 9 – Electronic Patient
Identification
 Need clinical review or action
 Taking a particular medication
 Need preventive care
 Need specific tests
 Need follow up visits
 Might benefit from disease or case
management support

18. PPC 9 – Electronic Care
Management Support
 Communicate with disease or care
managers
 Web-based educational modules for
patients with three clinically important
conditions

19. Recommendations
 Update Current Electronic Health Record
– Include basic patient information such as
marital status, race, language preference,
– The ability to store age-appropriate
preventive data
– Test Tracking
– Referral Tracking

20. Recommendations
 Interactive Website
– Allow patients access to their medical records
– Secure e-mail access to provide
communication between patients and
clinicians
– Web-based educational modules
– Report results on nationally approved
measures to their patients and the public

21. Timeline For Implementation

22. Mock NCQA Assessment
 Currently score 91 out of a possible 100
points
 Meet 9 of the 10 Must Pass Elements
 Level 1 certification