Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial

Introduction: Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. Methods: We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. Results: 2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. Discussion: A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. Conclusion: Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.


In-Person Access
Surveys a sample of its population on satisfaction with in-person access to care and reports results.
Surveys a sample of its population on in-person access to care using one of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey tools Surveys a sample of its population using one of the CAHPS survey tools, and meets a benchmark with patient satisfaction in access to care.

After Hours Access-4 hours
Offers access to in-person care at least 4 hours weekly outside traditional business hours.

HVE
After Hours Access-12 hours Offers access to in-person care at least 12 hours weekly outside traditional business hours. Follows up on patient hospitalizations and ED visits 70% of the time (when they have the information).

Utilization Prevention
Selects and reviews utilization measures and goals most relevant to their overall patient panel, or an at-risk patient population.
Shows improvement or meets a benchmark in utilization metrics on measures closely linked to utilization.

Population Data Management
Demonstrates the ability to identify, aggregate, and display up-to-date data regarding its patient population.
Demonstrates the ability to identify, track and proactively manage the care needs of a sub-population of its patients using up-to-date information.

Clinical Information Exchange-shares electronically N/A N/A
Has an electronic health record and demonstrates meaningful use of the electronic record, according to the Centers for Medicare and Medicaid rules.

Care Coordinationdescribes process
Assigns individual responsibility for care coordination and tells each patient or family the name of the team member responsible for coordinating his or her care.
Describes and demonstrates its process for identifying and coordinating the care of patients with complex care needs.

Test & Results Tracking
Demonstrates tracking of tests ordered by its clinicians and ensures timely and confidential notification or availability of results to patients and families with interpretation, as well as to ordering clinicians.
Comprehensive Care Planningdemonstrates ability N/A Demonstrates the ability to identify patients with high-risk environmental or medical factors, including patients with special health care needs, who will benefit from additional care planning. PCPCH demonstrates it can provide these patients and families with a written care plan that includes the following: self-management goals; goals of preventive and chronic illness care; action plan for exacerbations of chronic illness (when appropriate); end of life care plans (when appropriate).

Referral & Specialty Care Coordination
Demonstrates tracking referrals ordered by its clinicians, including referral status and whether consultation results have been communicated to patients and/or caregivers and clinicians.
Either manages hospital or skilled nursing facility care for its patients or demonstrates active involvement and coordination of care when its patients receive care in these specialized care settings.
Tracks referrals and coordinates care where appropriate for community settings outside the PCPCH (such as dental, educational, social service, foster care, public health, or long term care settings).

HVE
Care Plan Utilization-for a % of high-risk patients Reports data on care plans provided to high-risk patients.
Provides care plans to > 25% of highrisk patients.
Provides care plans to >50% of high-risk patients.

Advance Directive Utilization
Tracks offers of advance directives to patients over 65.
Offers advance directives to at least 30% of patients over 65.
Offers advance directives to at least 50% of patients over 65.

Performance Data Utilization
Uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

Care Coordination
Outreach-for a % of high-risk patients Care coordination outreach reaches 25% of high-risk patients.
Care coordination outreach reaches 50% of high-risk patients.

Education & Self
Management Support-documents Documents patient and family education, health promotion and prevention, and self-management support efforts, including available community resources.

Experience of Care
Surveys a sample of its patients and families at least annually on their experience of care. The patient survey must at least include questions on access to care, provider communication, coordination of care, and practice staff helpfulness. The recommended patient experience of care survey is one of the CAHPS survey tools.
Surveys a sample of its population using one of the CAHPS survey tools.
Surveys a sample of its population using one of the CAHPS survey tools and meets benchmarks on a majority of the survey domains.

HVE
Education and Selfmanagement Resources More than 10% of all unique patients are provided patientspecific education resources.
More than 10% of all unique patients are provided patient-specific education resources and selfmanagement services.