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Multipayer patient-centered medical home implementation guided by the chronic care model
Robert A Gabbay1, Michael H Bailit, David T Mauger
1Division of Endocrinology, Diabetes and Metabolism, Penn State College of Medicine, USA. rgabbay@hmc.psu.edu
Joint Commission Journal on Quality and Patient Safety
|June 29, 2011
Summary
Pennsylvania
Area of Science:
- Health Services Research
- Primary Care Transformation
- Chronic Disease Management
Background:
- A statewide multipayer initiative in Pennsylvania implemented the Patient-Centered Medical Home (PCMH) model.
- The Chronic Care Model (CCM) guided the initiative, targeting diabetes care.
- This represented a large-scale CCM implementation with payment reform across diverse practices.
Purpose of the Study:
- To evaluate the impact of PCMH and CCM implementation on diabetes care.
- To assess improvements in evidence-based screening and therapies for diabetes patients.
- To determine the effectiveness of multipayer infrastructure payments in supporting primary care transformation.
Main Methods:
- 105 practices and 382 primary care providers participated in regional learning collaboratives.
- Practices utilized Breakthrough Series learning collaboratives and practice coaches.
- Monthly quality reporting and multipayer payments supported implementation.
Main Results:
- All practices achieved at least Level 1 NCQA PPC-PCMH recognition within the first year.
- Significant improvements were observed in evidence-based complications screening and use of key therapies (statins, ACE inhibitors).
- Statistically significant improvements in blood pressure and cholesterol levels were noted, particularly in high-risk patients.
Conclusions:
- Implementing PCMH and CCM, supported by multipayer payments, shows promise for improving diabetes care.
- This initiative demonstrates a viable model for transforming primary care delivery.
- The findings support the integration of payment reform with care delivery models for chronic diseases.
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