The Carolinas Center for Medical Excellence (CCME) - North Carolina's Medicare Quality Improvement Organization (QIO) through July 2014 - helped a single-physician practice based in Lexington, NC, receive a Level 3 Patient-Centered Medical Home certification from the National Committee of Quality Assurance (NCQA). To be considered for a PCMH distinction, the three-person staff at the practice had to achieve the following six standards:
- Report specific data that supports the PCMH standards, which include enhancing access and continuity by accommodating patients’ needs with access and advice during and after hours and providing team-based care.
- Identify and manage patient populations by collecting and using data.
- Plan and manage care by following evidence-based guidelines for preventive, acute, and chronic care management.
- Provide self-care support and community resources.
- Track and coordinate care by way of tests, referrals, and care transitions.
- Measure and improve performance through patient experience data and quality improvement strategies.
In order to successfully achieve the sixth standard, the practice looked to CCME to help it effectively collect and monitor performance measurement data for its PCMH reporting efforts. The practice successfully achieved the highest level of PCMH distinction and continues to provide comprehensive, cost-effective, and patient-centered care through:
- Developing care plans for four chronic disease diagnoses: diabetes, hypertension, hyperlipidemia, and depression
- Printing and distributing notes from patient visits to patients
- Offering educational resources which are regularly updated on the practice’s website
- Providing phone reminders to each patient before his or her visit
The practice participated in CCME’s Cardiac Population Health Learning and Action Network and its Physician Quality Reporting System assistance program.