What is a PCMH NCQA practice? PCMH practices (patient-centered medical homes) recognized by the NCQA (National Committee on Quality Assurance) exemplify a different kind of care, where improved coordinated services for patients and increased satisfaction among providers are just some the ingredients for an overall improved system.
Under the strong leadership of Suzanne Fields, Chief of General and Geriatric Medicine, these changes were implemented. Dr. Fields reviewed the PCMH guidelines and knew she could apply the necessary improvements. A small leadership committee led by Dr. Susan Lee was created, and the journey began.
Now two locations of the General Medicine practice in the Department of Medicine have been recognized as PCMH sites: East Setauket and Commack. The academic faculty/general medicine practice at Stony Brook Medicine faced the initial challenge of making transformative change in two separate locations, but ultimately achieved their goal.
They partnered with HANYS PAS Solutions, a company that provides a full range of services to assist clients in maintaining their objectives with respect to medical home practice transformations.
The PAS team (Practice Advancement Strategies) began the process with fundamental building blocks:
-an assessment and gap analysis of the practice to determine workflows
-workflow redesign and changes in policies and procedures, based on the assessment
-changes in the EMR system so the practice could truly benefit in switching from paper to electronic records
Another key spotlight was being a better “medical neighbor.” This focus involved reaching out and partnering with specialty groups about responsibilities and expectations of communication and care coordination. For example, the Stony Brook team now tracks referrals through a new system that designates them urgent (within 2 weeks) or STAT (within 3 days.) The EMR system provides overall improved communications, allowing the specialist and primary care physician to communicate via secure messaging.
“The more we communicate with each other,” says Dr. Lee, “the better we are at taking care of and advocating for our patients.”
What were some of the results of Stony Brook’s journey?
-a dramatic decline in the 30-day readmission rates among Medicare patients
-increased colon care and breast cancer screening rates
-improved glucose control among diabetic patients
-increased screening for Hepatitis
-strengthened pain management
The practices also addressed the “people” side of change, which extended beyond workplace procedures to help staff members embrace the new paradigm. Nicole Harmon, VP of HANYS Solutions, says “It’s not enough to just change workflow, policies and procedures…practices need to help their providers and staff members embrace change.”
“It’s a continuing journey to transformation,” said Dr. Lee. “PCMH will continue to grow and evolve, and so will we.”
