In September 2012, Housecall Providers (HCP) was recognized as a Patient Centered Primary Care Home (PCPCH) by the Oregon Health Authority. This innovative model is designed to help transform the way primary care practices deliver care to improve patient health and lower costs. It encourages strong relationships with patients and families, treating the whole person, and coordinating comprehensive care.
Because of our selection, HCP is eligible to receive supplemental funds for a subset of Medicaid patients with complex health diagnoses who have received certain non-billable core services that we provide. In the months since we were recognized, we have been working diligently to justify our inclusion in this select group of providers, and we anticipate recovering some of the costs we can’t usually bill for. We have made progress already.
To receive this recognition, HCP had to confirm that we meet the program’s required standards, practices that we were already undertaking. Among them:
- providing medical consultation 24 hours a day, seven days a week
- assigning patients to a specific primary care provider (PCP)
- coordinating patients’ health care
- making a concerted effort to follow up with patients within a week of hospital discharge
- using electronic medical records
- discussing goals of care with patients and family
- making referrals and connections to community services
To receive the supplemental Medicaid funding, we are documenting patient-centered health plans for the 479 qualifying Medicaid patients that include the goals and concerns of the patients, when they are able to express them, and their families or representative when they are not.
Polly Green, MSW, is coordinating and monitoring our involvement in PCPCH and is currently in the midst of contacting these patients and their families. Polly has already reached 400 patients and/or family members asking them to elaborate on specific treatment goals or if there has been anything that their PCP might be missing.
These goals (examples include fewer hospitalizations, more visitors for the patient, summer outings, and keeping the patient comfortable and pain free) are put into a plan and attached to the patient’s file so that the PCP and patient and/or family member can create a way, if at all possible, to obtain the stated goals or negotiate new ones.
“What PCPCH has done is bring the voice of the family into the patient’s care in a greater capacity,” Polly says. “Ideally, we would be having this conversation with the patient. But since the majority of our patients cannot speak for themselves, the family or the patient’s representative has to step into the advocate role and assist with the plan. Ultimately the plans will improve our ability to guide the care our patients receive.”
To read more articles from the HCP eNew June 2013 click here.