Title and Citation

Summary

Format

Behavioral Health Integration: Blending Behaviorists into the Patient Centered Medical Home

This conference slide presentation stresses the imperative for integrating behavioral specialists into the PCMH model, distinguishing between true integration and mere co-location of services. The author describes the model presently in operation at Cherokee Health Systems in Knoxville, Tennessee.

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(900 KB)

Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home

The report unambiguously calls for the integration of behavior specialists into the PCMH, with particular attention to the IMPACT model, which emphasizes real-time collaborative care by a physician and a behavior specialist to deliver effective behavioral healthcare. The paper also identifies current systemic barriers (financing, regulation, privacy policies, and so on) that must be addressed to optimize the opportunity to realize meaningful patient and clinician outcomes. Copyrighted.

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(660 KB)

Behavioral Integrative Care: Treatments That Work in the Primary Care Setting

Integrated care is one of the most important developments in the delivery of health care. In this practical volume, contributors address specific health problems that can be aided with integrated care to the benefit of the patient. Clinical psychologist and psychiatric social workers looking to expand their practice will find this volume of interest.

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Building the Person-Centered Healthcare Home of the Future

This training presentation was part of a SAMHSA-funded Mental Health Transformation State Incentive project. The training seeks to build a knowledge base within state government regarding the integration of mental health and substance use services in primary care and the integration of primary care into specialty mental health and substance use settings. Desired outcomes of the training are for state agency programs, policies and financing options be shaped by a consistent vision of how integrated services are delivered, and how program, policy and financing decisions align to this vision.

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(1 MB)

Building Medical Homes: Lessons from Eight State with Emerging Programs

Eight states profiled in this report are at different stages in the development and implementation of PCMH programs and have relied on different strategies to encourage adoption of the model. Their experiences demonstrate that states can play a critical role in helping practices improve performance and can productively address systemic barriers such as those that can lead to conflict among payers.

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(550 KB)

Changes Involved in Patient-Centered Medical Home Transformation

The patient-centered medical home model has been proposed by the major primary care professional societies as a way to achieve more effective, less costly care. Commonwealth Fund-supported researchers reviewed the professional literature and convened a panel of experts to identify characteristics of fully transformed medical homes and the necessary changes to infrastructure, organization, and care delivery that practices and clinicians must make to get there. (Only the abstract is in the public domain.)

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Consensus Operational Definition of Patient-Centered Medical Home (PCMH) Also known as Health Care Home

To develop an operational definition of "PCMH" useful for implementers, payers, policy makers and others, researchers from the University of Minnesota and the Institute for Clinical Systems Improvement engaged a core and a secondary group of sector stakeholders who collaboratively developed a consensus definition of PCMH that encompasses both essential functionalities and reasonable variations, as delimited by specific parameters. The report's methodology is explained in detail. (Protected by copyright.)

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Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home-Challenges and Solutions

This paper explores the current landscape of PCMH services for patients with complex needs, details five programs that have addressed the challenges of caring for these patients, and offers programmatic and policy changes that can help smaller practices better deliver services to all patients. PCMHs offer a promising model for providing comprehensive, coordinated care. Smaller practices, however, face particular challenges in coordinating care for these patients.

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(2.1 MB)

Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide

This how-to guide was developed by the AHRQ to support organizations interested in starting a practice facilitation program for primary care transformation in light of the growing consensus that the U.S. primary care system must be redesigned in fundamental ways to improve health and patient experience and lower costs.

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(3 MB)

Developing the Medical Home in Primary Care: Using a Patient Navigator to Coordinate Care

Overlook Hospital Foundation funded a pilot project to demonstrate how patient navigators can help improve care coordination for patients of primary care practices. This is a report of the types of services the navigator provided, the barriers and facilitators to patient navigation in primary care practices, and understanding patients', physicians' and the navigator's perspectives and experiences with this service. (Online only.)

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Early Detection and Treatment of Substance Abuse Within Integrated Primary Care (Healthcare Utilization and Cost Series, V. 7)

Substance abuse is a major public health concern, affecting millions of people in the United States. Given its far-reaching impact on the welfare of society, healthcare professionals should make substance abuse a priority. Most patients with substance abuse problems present in primary care settings, oftentimes with other complaints. When professionals, working in primary or integrated care settings, know what to look for and there is adequate infrastructural support with respect to triage, implementing substance programs with an eye on early detection and intervention can dramatically improve health outcomes and create significant financial benefits.

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Engaged Leadership: Transforming Safety Net Clinics into PCMHs (Implementation Guide)

SNMHI developed this implementation guide to help leaders drive and sustain PCMH transformation in their organizations. The guide uses the Institute for Healthcare Improvement's (IHI) Seven Leadership Leverage Points for Organization-Level Improvement in Health Care framework to explain the areas in which leaders can most effectively use their time and energies to drive and sustain transformation.

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(2.1 MB)

Evidence about the Role of the Patient Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety

This slide presentation begins with an overview of the PCMH model and accountable care system, discusses how both can improve quality and safety, and provides examples of specific practices that are implementing change towards those aims.

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(600 KB)

Evolving Models of Behavioral Integration in Primary Care

A primer on integrated care that includes both a description of the various models along the continuum and a useful planning guide for those seeking to successfully implement an integrated care model in their jurisdiction.

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(650 KB)

From Striving to Thriving: Systems Thinking, Strategy, and the Performance of Safety Net Hospitals

Leading researchers explored the organizational characteristics of higher-performing Safety-net institutions. Strategic management, more so than structural characteristics, plays a critical role in thriving safety-net hospitals. Those that prosper have an understanding of the full spectrum of patient needs, seek partners to complement their operations, and limit services to those in which their organizations perform well. (Only the abstract is in the public domain.)

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Geisinger Health System: Achieving the Potential of System Integration Through Innovation, Leadership, Measurement, and Incentives

Pennsylvania's Geisinger Health System is a physician-led, non-profit integrated delivery system serving approximately 2.6 million. Geisinger's objectives are to simultaneously improve quality, satisfaction, and efficiency only by redesigning and reengineering the delivery of care. This philosophy is epitomized by ProvenCare, a portfolio of products for which care processes have been redesigned to reliably administer a coordinated bundle of evidence-based best practices. Use of the ProvenCare model has improved clinical outcomes while decreasing resource utilization.

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(1.4 MB)

Genesys HealthWorks Integrates Primary Care with Health Navigator to Improve Health, Reduce Costs

The Institute for Healthcare Improvement's Triple Aim Initiative has developed a report series to catalog Triple Aim model program progress. This overview describes Genesys HealthWorks in Michigan, which has focused on integrating care in primary care practices by adding health navigators to the care team.

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(440 KB)

Getting Started with Maryland's Patient Centered Medical Home Program

The objective of the Maryland Health Care Commission PCMH pilot program is to evaluate whether the PCMH model provides higher quality, more efficient care, and higher satisfaction for patients, nurse practitioners, and primary care physicians. The Pilot was designed to reward medical homes for the additional services, while creating a viable economic model for health care purchasers and maintaining administrative simplicity given multiple payers, diverse physician practices, and our desire to avoid risk selection against sicker patients.

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(700 KB)

Guiding Transformation: How Medical Practices can Become Patient-Centered Medical Homes

This report provide an assessment of the changes that most medical practices would need to make to become PCMHs. The broad changes include: engaged leadership; a quality improvement strategy; empanelment to ensure the continuity of the patient-provider relationship; continuous and team-based healing relationships; evidence-based care; increased patient involvement in their own care; enhanced access; and care coordination.

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(330 KB)

Health Navigators Support Self-Management With Primary Care Patients, Leading to Improved Behaviors and Lower Utilization

Using a combination of health coaching, case manager, and care coordinator skills, health navigators help insured and uninsured patients cared for by PCMHs adopt healthier behaviors and better manage chronic diseases. This review of Genesys HealthWorks' health navigator model found that navigators improved lifestyle-related and self-management behaviors, leading to better health outcomes and significant reductions in emergency department and inpatient utilization.

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(160 KB)

Integrating a Behavioral Health Specialist Into Your Practice

This peer-reviewed article identifies and discusses the positive outcomes of integrating behavioral health specialists in primary care practices, addressing such factors as increased efficiency; increased patient and physician satisfaction; improved health outcomes; and improved mental health outcomes. (Only the abstract is in the public domain.)

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Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State Mental Health Authorities

The National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council commissioned this overlay analysis of The Four Quadrant Clinical Integration Model and The Care Model approaches to integrated healthcare to establish baseline data on states' implementation of and to elicit recommendations in the areas of: Community Health Centers and their role in providing behavioral health services; needs of the people served by state mental health authorities; and evidence for integrating behavioral health services into primary care.

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(510 KB)

Integrating Mental Health Treatment into the Patient Centered Medical Home

A discussion of the PCMH model for improving quality and efficiency of primary in the context of mental health services integration, including a review of PCMH and current strategies used to deliver mental health treatment in primary care. The authors outline programmatic and policy changes that can facilitate integration of high-quality mental health treatment within a PCMH.

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(200 KB)

Integrating Primary Care & Mental Health-Substance Use

The objective of this review was to describe the integration of collaborative medication therapy management (CMTM) into a safety net PCMH. Researchers studied a FQCH for homeless individuals over a 21-month period. Reviewers found that integrated CMTM was a valuable patient-centered strategy for addressing medication-related problems among homeless individuals. (Abstract only in public domain.

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Maximizing Team-Based Care in the Patient-Centered Medical Home

Implementing care teams is a critical element of transforming a practice into a patient-centered medical home. This guide presents a curriculum and provides training materials (PowerPoint presentations, handouts, skill assessments, exams, etc.) that practices can use to enhance the skills of Medical Assistants and Clinical Assistants.

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(2 MB)

Next Level Transformation-Care Coordination and Care Managers

A review of the shortcomings of traditional (specialized) medical practices in is followed by a description of the care coordination inherent in the PCMH model. Wagner emphasizes the need to build in accountability, patient supports, and care coordination.

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(270 KB)

Patient-Centered Innovation in Health Care Organizations: A Conceptual Framework and Case Study Application

Patient-centered innovation is spreading at the federal and state levels. The authors propose a framework for understanding the process of initiating patient-centered innovations. The study identifies elements that will lead to implementation success: effective leadership, motivation to change; organizational mission, strategy, and capacity, continuous feedback and organizational learning. (Only the abstract is in the public domain.)

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Physician "Costs" in Providing Behavioral Health in Primary Care

Previous research has shown that behavioral health concerns lengthen primary care visits. This study is the first to quantify those effects on pediatrician reimbursement. Integrating behavioral health services allows physicians to refer patients with behavioral issues to in-house specialists. These, in turn, can address the behavioral health issue and are licensed to receive mental health reimbursement. (Only the abstract is in the public domain.)

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Primary and Behavioral Healthcare Integration: Guiding Principles for Workforce Development

This concise fact sheet identifies barriers to workforce integration; sets out CIHS' goals and the principles that will inform its workforce development planning efforts; and includes Recommended Strategies for Training and Education, Recruitment and Retention, Leadership, Persons in Recovery, Community, Infrastructure Development, and Research and Evaluation.

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(1 MB)

Primary Care and Healthcare Reform

This AAFP annual scientific assembly presentation provides a review of the main issues facing primary care physicians, practices and networks: payment issues, health delivery systems reforms, coverage changes, cost containment provisions, and workforce development.

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(500 KB)

Primary Care Toolkit: Practical Resources for the Integrated Behavioral Care Provider

The integration of behavioral health into the medical setting brings effective, coordinated treatment and increased satisfaction for both practitioner and patient. In reality, however, the results can be far from perfect-and far from integrated. The Primary Care Toolkit introduces mental health professionals to the best possibilities for the collaboration while preparing them for the crucial differences between primary care and traditional mental health settings, to make the transition as worthwhile and non-traumatic as possible.

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Principles for Patient and Family Centered Care: The Medical Home from the Consumer Perspective

The National Partnership for Women and Families has prepared a 9-point set of principles to guide health care providers and patients in the development and implementation of the PCMH model of care.

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(400 KB)

QuadMed's Onsite Clinics Reduce Corporate Costs, Enhance Care

The Institute for Healthcare Improvement's Triple Aim Initiative has developed a report series to catalog Triple Aim model program progress. This overview describes QuadMed, which is based in Wisconsin, but whose innovative approach is to co-locate practices with businesses in four states in addition to Wisconsin.

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(360 KB)

Recommended Core Measures for Evaluating the Patient-Centered Medical Home: Cost, Utilization, and Clinical Quality

Initiatives across the country are testing the promise of the medical home model. To properly evaluate and compare results that will aid in the implementation of these and other initiatives, researchers need a standard set of core measures. This brief describes the process and recommendations of more than 75 researchers who came together to identify a core set of standardized measures to evaluate the patient-centered medical home. The focus is on two domains of medical home outcomes: cost/utilization and clinical quality.

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(1 MB)

Skills Required for Mental Health Providers Integrated into Primary Care

MaineHealth has developed a synopsis of core competencies for mental health providers in primary care that describes the skill sets needed and makes recommendations to providers about how to establish mental health services in primary care setting.

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(40 K)

Strategies to Put Patients at the Center of Primary Care

AHRQ encourages medical practice decision makers to promote greater patient engagement in their own care, quality improvement in the practice, and in the development and implementation of policy and research. Putting the patient at the center of the PCMH is one key to ensuring that this health care delivery model meet patients' needs and achieves its potential for improving health.

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(108 KB)

Transforming Community Health Centers into Patient-Centered Medical Homes: The Role of Payment Reform

This report examines how changes in the way federally qualified health centers (FQHCs) are financed could support the transformation of these critical safety-net providers into high performing patient-centered medical homes. Through surveys and interviews, the authors explore the current landscape of health center involvement in medical home initiatives, adoption of medical home standards, and receipt of payment incentives. Based on their findings, the authors make preliminary recommendations to encourage health centers to serve as patient- and community-centered medical homes.

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(430 KB)