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Patient-Centered Care in a Medical Home

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M. Colette Carver, MSN, APRN-BC-ADM, FNP
Anne T. Jessie, MSN, RN


There is general consensus that our current healthcare delivery system will not be able to supply an adequate workforce, contain costs, and meet the ever-increasing chronic-care needs of the growing and aging population in the United States (US). Some of the major challenges to the U.S. healthcare system are faced by those on the front lines, namely the healthcare workers in primary care. Part of the emerging solution for primary care is the adoption of the Patient-Centered Medical Home Model. The intent of this model is to provide coordinated and comprehensive care rooted in a strong collaborative relationship. Carilion Clinic in Southwestern Virginia is implementing this patient-centered model in which a proactive, multidisciplinary care team collectively takes responsibility for each patient. In this article we will elaborate on the concepts of patient-centered care and patient-centered medical homes, after which we will offer an exemplar describing the process that Carilion Clinic is using to establish patient-centered medical homes throughout their primary care departments. Limitations of the Patient-Centered Medical Home Model will also be discussed.

Citation: Carver, M. C., Jessie, A., (May 31, 2011) "Patient-Centered Care in a Medical Home" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 4.

DOI: 10.3912/OJIN.Vol16No02Man04

Key words: ambulatory case management, care team, Carilion Clinic, chronic disease registry, nurse care coordinator, patient-centered care, patient-centered medical home, PCMH, patient population management, primary care

Bates (2009) has observed that although healthcare in the United States (US) is the world’s most expensive, the outcomes we achieve are some of the worst among developed countries. The disparity between cost and quality is staggering. The Centers for Medicare and Medicaid Services have reported that our national health expenditures are 17.6% of the U.S. gross domestic product (2009). A widely accepted marker of overall national health is infant mortality. The US is ranked 29th in infant mortality, according to the U.S. Department of Health and Human Services (2008). The Commonwealth Fund, a private foundation working to improve healthcare, has reported that the US ranks seventh in healthcare safety, efficiency, and equity (2010). The Commonwealth Fund further reported that the highest performing countries have primary care as the centerpiece of their healthcare delivery systems (Davis, Schoen, & Stemikis, 2010). The underperforming U.S. healthcare system, according to Fisher, Goodman, Skinner, and Bronner (2009) produces wide variances in care across the United States. This is attributed in part to a general lack of emphasis on primary care throughout our system.

There is mounting concern that our current system will not be able to supply an adequate workforce, contain costs, and meet the ever-increasing chronic-care needs of the aging population. There is mounting concern that our current system will not be able to supply an adequate workforce, contain costs, and meet the ever-increasing chronic-care needs of the aging population. Although Larson and Reid (2010) have provided evidence that primary-care-based systems produce higher quality at more affordable costs, the challenge rests with those in primary care to define and deliver this high quality care. A structured system is needed that can consistently deliver high quality clinical and service outcomes, while simultaneously quantifying the added value it provides. The system must coordinate and address all the chronic, acute, and preventive care needs of a specific patient population. Additionally, this structured system must be reproducible in various primary care office settings, from solo practitioners to large, integrated health systems.

The National Committee for Quality Assurance (NCQA) has defined this structured approach as the Patient-Centered Medical Home (PCMH). NCQA has defined common clinical and service metrics for primary care offices seeking medical home certification. These medical home guidelines serve as objective measurement tools for healthcare quality (NCQA, 2011b). Brown (2010) has concluded that compensating primary care providers for the added value they deliver will make primary care more professionally satisfying. As efforts are underway to feature primary care in the newly designed U.S. healthcare system, the value these professionals provide must be recognized. This is the first step in addressing the dwindling primary care workforce. Health system redesign was similarly recommended by The Dartmouth Institute for Health Policy and Clinical Practice in its publication of the Dartmouth Atlas Project, “Health Care Spending, Quality and Outcomes,” (Fisher, Goodman, Skinner, & Bronner, 2009). This twenty year project challenged existing assumptions as it “examined regional variations in the practice of medicine and in spending for healthcare, principally in the Medicare population” (Fisher et al., 2009, p. 1). The report concluded with the As efforts are underway to feature primary care in the newly designed U.S. healthcare system, the value these professionals provide must be recognized. dramatic finding, that higher spending does not result in improved patient perceptions of access to care or actual quality of care, nor does higher volume produce better patient outcomes. (Fisher et al., 2009, p. 2). The question is not whether to reform the U.S. health system but how to bring about this reform.

In this article we suggest that rigorous application of the PCMH model is a necessary and foundational first step in this transformation. We will begin with a discussion of both patient-centered care and patient-centered medical homes. Next we will offer an exemplar describing the process that Carilion Clinic is using to establish patient-centered medical homes throughout their primary care departments. Limitations of the Patient-Centered Medical Home Model will also be discussed.

Patient-Centered Care

Patient-centered care has been defined in many ways by various disciplines. The lack of a consensus regarding a definition of patient-centered care makes application of the concept challenging. In their review of the literature Mead and Bower (2000) explored various aspects of the relationship between the provider and the patient. Two of these concepts, patient-as-person along with sharing power and responsibility, are current areas of focus for those working to redesign the healthcare system. Each will be discussed below.

Patient-as-person involves an appreciation for the patient’s perception and expression of an illness and the recognition that the patient’s illness is a unique experience, one that is influenced by the patient’s attitudes, knowledge, and current personal or social context (Mead & Bower, 2000). Two patients can have varied responses to the same illness or chronic condition due to their different life experiences and circumstances. Self-management support is a key feature of the PCMH model. It has been shown to improve patient outcomes (Bodenheimer, Lorig, Holman, & Grumbach, 2002). The “central concept in self-management is self-efficacy - the confidence to carry out a behavior necessary to reach a desired goal” (Bodenheimer et al., 2002, p. 2469). Bodenheimer (2002) has depicted chronic disease self-management programs as including both teaching patients about their chronic disease and guiding patients as they apply newly acquired problem-solving skills to their daily disease management. Approaching patients as individuals, wherever they are in the current context of their illness, is an important part of self-management support (Schaefer, Miller, Goldstein, & Simmons, 2009). Kate Lorig, RN, a professor at Stanford University School of Medicine and the Director of the Stanford Patient Education Research Center, has made significant contributions to chronic disease care in medicine over the last twenty years with her community-based, peer-led, patient-self-management programs (Stanford, n.d). Lorig has observed that patients who have participated in self-management programs are better equipped to collaborate with their providers as they negotiate healthcare choices than those who haven’t participated in such programs (personal communication, April 14, 2010).

Because a patient’s expression and experience of illness may change from moment to moment, the provider’s relationship with the patient must remain flexible. The sharing of power and responsibility is another aspect of patient-centered care that is currently receiving considerable attention. The Institute of Medicine (IOM), in Crossing the Quality Chasm Report (2001), has recommended a paradigm shift from a provider locus of control to a patient locus of control (Berwick, 2009). Although opinions differ regarding the specific format of the relationship between patient and provider, most agree that a relationship between the patient and provider is important (Mead & Bower, 2000). Because a patient’s expression and experience of illness may change from moment to moment, the provider’s relationship with the patient must remain flexible. The treatment and support must reflect the intensity needed by the individual patient at a given point in time.

Unfortunately, even in a perfect setting, a busy clinician cannot realistically recognize all aspects of the patient as a person and work to share power and responsibility in a manner appropriate to each patient during the limited appointment time allotted. Mead and Bower (2000) have suggested that some clinicians may work to expand the appointment time to ensure patient-centered care. However, seeing fewer patients for a longer time is not a realistic solution in this era of a primary care workforce shortage. Additionally, the current reimbursement structure does not support expanded patient-centered services. Many innovative primary care providers are utilizing a team-based approach to deliver all care, be it acute, chronic, and/or preventive care, to their patients. These multidisciplinary teams may include, at various times, advanced practice nurses, ambulatory nursing staff, pharmacists, dieticians, and/or social workers. The specific professional(s) working with a given patient at any given time varies in a way that best serves the needs of the individual patient.

Patient-Centered Medical Homes

The PCMH model, as defined by the National Committee for Quality Assurance, provides a road map to define the internal structure of primary care and establish the goals needed to deliver patient-centered care and improve outcomes (Patient-Centered Primary Care Collaborative, n.d.). In 2008, the National Committee for Quality Assurance (NCQA) published the Physician Practice Connections® - Patient-Centered Medical Home™ (PPC-PCMH), the standard for certifying practices as medical homes. NCQA define a medical home as:

A model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has a relationship with a primary care clinican who leads a team at a single location that takes collective responsibility for patient care, providing for the patient’s health care needs and arranging for appropriate care with other qualified clinicians. The medical home is intended to result in more personalized, coordinated, effective and efficient care (NCQA, 2011c, p. 2.).

The Patient-Centered Medical Home (PCMH) is the dominant model currently proposed to redesign our healthcare system. The PCHM model is an approach to delivering comprehensive primary care for patients of all ages (Patient-Centered Primary Care Collaborative, n.d.). It is a major component of the healthcare reform bill that contains provisions to address cost, quality, and workforce shortfalls, and that has been signed by President Obama (Casalino, Ritterhouse, Gillies, & Shortell, 2010).

This significant legislation signed by President Obama was due in part to the foundational work of the Institute of Medicine (IOM). The IOM has provided numerous reports to Congress regarding the state of the U.S. healthcare system (IOM, n.d.). The IOM’s well known work, Crossing the Quality Chasm: A New Health System for the 21st Century (2001), called for a comprehensive redesign of the entire healthcare delivery system with a more patient-centered focus, thus challenging many current paradigms in medicine. This IOM work defined the concept of patient-centeredness as “care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions” (p. 6). The report is best known for its commitment to patient-centered care as stated in the ‘Six Aims for Improvement’ (Table 1) and the ‘Ten Rules for Redesign’ (Table 2). The six aims focus on the actual delivery of care, while the ten rules address needed change within the healthcare system.


Table 1. Six Aims for Delivery of Care (IOM, 2001)


Avoiding injuries to patients


Providing services based on evidence to only those who may benefit


Providing care that is respectful of and ensures that patient values guide all clinical decisions


Reducing waits and harmful delays


Avoiding waste of equipment, supplies, ideas, and energy


Providing care that does not vary in quality because of personal characteristics


Table 2. Ten Rules for Redesign of the Health Care System (IOM, 2001)

  • Care is based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits.
  • Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should have the capability to respond to individual patient choices and preferences.
  • The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over healthcare decisions that affect them.
  • Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge.
  • Decision making is evidence based. Patients should receive care based on the best available scientific knowledge.
  • Safety is a system property. Patients should be safe from injury caused by the care system.
  • Transparency is necessary. The system should make available to patients and their families information that enables them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments.
  • Needs are anticipated. The system should anticipate patient needs, rather than simply react to events.
  • Waste is continuously decreased. The system should not waste resources or patient time.
  • Cooperation among clinicians is a priority. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.


This model is being widely implemented, as evidenced by the growing data base of certified providers and medical homes on the NCQA’s web site (2011). The PCMH model originated with the American Academy of Pediatrics in the late 1960’s as pediatricians were making efforts to coordinate care for special needs children (Larson & Reid, 2010). It has been repeatedly redefined by multiple physician groups. The model currently “...combines traditional concepts of primary care (a personal physician providing first contact, continuous, and comprehensive care) in [the] guiding [joint] principles” (henceforth referred to as Joint Principles) (Casalino et al., 2010, p. 1555). These Joint Principles of the PCMH model were agreed upon in 2007 by the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association, representing over 300,000 physicians. It has been subsequently endorsed by the American Medical Association and eighteen specialty healthcare organizations (Patient-Centered Primary Care Collaborative, 2010, para 2). The widely agreed upon Joint Principles (described below) define the intent of patient-centered care, while NCQA’s certifying standard, discussed above, is the guide book for medical home model implementation. The following are the seven Joint Principles along with a brief description of each principle:

  • Personal physician: Each patient has an ongoing relationship with a personal physician who is trained to provide first contact, continuous, and comprehensive care. The intent here is that patient-centered care is built on the foundation of the patient-provider relationship.
  • Physician directed medical practice: The personal physician at the practice level leads a team of individuals that collectively take responsibility for ongoing patient care. The intent is to encourage physicians to adopt a team approach when meeting the varied needs of their patient population.
  • Whole-person orientation: The personal physician is responsible for providing all of the patient’s healthcare needs or for arranging care with other qualified professionals. The intent again, is to encourage a team approach in meeting all patients’ acute, chronic, and preventive care needs.
  • Care is coordinated and integrated: Coordination occurs across all elements of the complex healthcare system and the patient’s community. The intent here is to foster collaboration between all care providers, such as specialty and home health providers and community-based services. The use of disease registries, information technology, and health information exchanges is encouraged, ensuring that patients get the care they need in a culturally and linguistically appropriate manner.
  • Quality and safety: These are the hallmarks of the medical home. The intent here is that care be patient, system, and physician focused. The patient is supported in disease management and is able to provide regular feedback to the care team. The system maximizes the information technology through performance reporting, clinical-decision support for clinicians, patient education, and online communication. The physician accepts accountability for numerous ongoing quality improvement activities and participates in a certification program.
  • Enhanced access: Care is available through open scheduling, expanded hours, and other innovative options for communication between patients, their personal physician, and practice staff. The goal here is to continuously improve access, be it in person, by telephone, or though a secure, web-based patient portal.
  • Payment: This principle recognizes the added value provided to patients who have a patient-centered medical home so as to promote sustainability of the model. Delivering an advanced level of primary care takes a team of professionals routinely working together to provide patient-centered services. This work is documented in the quality reporting noted in the fifth Joint Principle. Expanded services beyond the actual patient encounter need to demonstrate value, such as improved health outcomes, before increasing reimbursement (Patient-Centered Primary Care Collaborative, n.d.).


An Exemplar: Promoting Patient-Centered Care in a Medical Home

The practice team typically includes a physician, lead nurse, office manager, and nurse care coordinator. In this exemplar we’ll explain how the organization in which we work is implementing the PCMH model and note our preliminary outcomes. Carilion Clinic is an integrated healthcare system with approximately 600 physicians serving one million people in Central and Southwest Virginia. The system includes approximately 12,000 healthcare workers and eight not-for-profit hospitals. The Primary Care offices are staffed by 180 physicians along with a combined total of 75 nurse practitioners and physician assistants. The Department of Primary Care (DPC) has committed to adopting the PCMH model in all their practices, so as to provide excellent patient-centered care that is disciplined and coordinated. This DPC commitment is the initial, foundational step in this larger health-system-wide project.

Carilion is part of an Accountable Care Organization (ACO) pilot project, collaborating with the Dartmouth and The Brookings Institute. An ACO strives to be equally accountable on both cost and quality initiatives throughout the organization (Carilion Clinic, 2010). The ACO’s success is built on a disciplined and coordinated primary care foundation. The adoption of the medical home model by the Department of Primary Care is well underway. To date a third of all Carilion’s primary care offices have received medical home certification. This initiative follows the success of other market leaders, for example, the Group Health Cooperative, a nonprofit health-insurance and care-delivery system based in Seattle (Larson & Reid, 2010). Carilion is focusing on five strategic initiatives necessary to establish and sustain the model: (a) adopt the Seven Joint Principles of the Patient-Centered Medical Home, (b) create a culture of improvement,; (c) fully leverage the electronic medical record (EMR), (d) obtain NCQA Level 3 certification, and (e) participate in medical home research. These initiatives are presented in Table 3 and further described below the Table.


Table 3. Carilion’s Five Strategic Initiatives and Corresponding Objectives



  1. Adopt the Seven Joint Principles of the Patient-Centered Medical Home Model

Create system policies that reflect the Joint Principles and establish the supporting office workflows.

  1. Create a culture of improvement

Engage in a formal process of quality improvement focusing on both service and clinical outcome measures.

  1. Fully leverage the EMR

Coordinate efforts to systematically input accurate patient data into the EMR, and export meaningful reports from this data.

  1. Obtain NCQA Level 3 Certification

Maximize all aspects of patient-centered care and deliver excellent primary care.

  1. Participate in Medical Home Research

Innovate in primary care delivery and demonstrate improved outcomes.


Adopting the Joint Principles

Implementing these shared policies and designing the workflows needed to meet them has provided a structured guide to ensure patient-centered care is being delivered... The first initiative, namely adopting the Joint Principles, reflects Carilion’s dedication to the “traditional concepts of primary care (a personal physician providing first-contact, continuous, and comprehensive care)” (Casalino et al., 2010, p. 1555). Carilion uses an internal, medical-home-transformation team to facilitate the entire process, beginning with the introduction of the Joint Principles. The facilitators comprise a multidisciplinary team consisting of a quality specialist, a nurse practitioner, a physician, and information technology staff. The facilitators have remained constant through this process, guiding all the primary care practices. Each primary care practice identifies an internal team to lead the medical home implementation. The practice team typically includes a physician, lead nurse, office manager, and nurse care coordinator. The care coordinator is either a registered nurse or licensed practical nurse. Carilion designed this new ambulatory nursing role to expand the care delivered in each of their primary care practices so as to deliver fully on the intent of each of the Joint Principles. Each care coordinator works with four physicians managing their patient populations. Other aspects of the care coordinator’s role in the medical home will be detailed in the following sections. The practice team becomes familiar with the role of the care coordinator as they review in detail the Joint Principles and NCQA’s certifying standard.

Larson and Reid (2010) have stated the Joint Principles basically reflect good primary care. Although we agree with this assertion, this level of care is not a reality in all primary care offices at the national level. The medical home facilitators analyze many aspects of the practice, including the patient population, the practice’s workflows and staffing mix, and the availability of current policies and protocols. Carilion’s primary care offices are being strengthened by the sharing of policies. Implementing these shared policies and designing the workflows needed to meet them has provided a structured guide to ensure patient-centered care is being delivered, as required by the NCQA standard.

Creating a Culture of Improvement

The care teams collectively take responsibility for their patient populations. They use daily huddles, which are ten-minute mini meetings, to prepare for the upcoming day. The second initiative, creating a culture of improvement, establishes a formal process of quality improvement within each practice. The medical home facilitators manage this improvement process. The facilitators work with the practice team to identify opportunities to improve clinical and service measures. Each practice begins by focusing on small-scale improvements, setting the stage for innovation in everyday workflow. Service measures, such as telephone and email response time, and/or patient appointment availability, are reviewed by the practice team. Opportunities for improvement are identified and a quality improvement plan is developed with the facilitators. Similarly, clinical measures are reviewed and improved upon in the same fashion, by the physician, nurse, and nurse care coordinator who comprise the core care team.

All members of the staff consistently report increased satisfaction with this new level of ownership of the patient population. The care teams collectively take responsibility for their patient populations. They use daily huddles, which are ten-minute mini meetings, to prepare for the upcoming day. The care coordinator leads this effort, performing preliminary chart reviews identifying those patients with poor chronic disease control and those with overdue health maintenance measures, such as immunizations or mammograms. In this way the care team reviews selected patients who are in need of additional care. This outcomes-driven team approach to patient care reinforces the culture of improvement. All members of the staff consistently report increased satisfaction with this new level of ownership of the patient population. The office culture is transformed from a set of static workflows to a dynamic environment of empowered professionals who work together to improve numerous clinical and service outcome measures.

Leveraging the Electronic Medical Record

The third strategic initiative is leveraging the Electronic Medical Record (EMR). One EMR system is used throughout all of Carilion Clinic, from the ambulatory offices to the in-patient settings. There is ongoing optimization of EMR use to ensure accurate and systematic data entry. Dedication to this optimization process has yielded accurate reporting of patient data. These reports are being used in the population management work of primary care. A typical provider’s panel (the population of patients that need to be managed by the care team) is 2,500 patients. We are currently focusing on two key areas of population management, namely transitions in care and chronic disease care.

A current medication list, the discharge summary, and the care plan for each patient are readily available in the EMR. When a patient transitions from a hospital to a nursing home or back into the care of the primary provider, there are many opportunities for medical errors to occur. The use of one EMR system allows the care coordinators in the primary care offices to observe and review these patient transitions and reach out to those who may need extra support. A current medication list, the discharge summary, and the care plan for each patient are readily available in the EMR. There are a number of teams within Carilion working on workflows for safe transitions; the shared EMR supports these communication efforts.

The second area of population management in the primary care offices focuses on the patient’s level of chronic disease control. Chronic Disease registries have been created within the EMR. The registries are lists of patients with a chronic disease, organized by conditions and the assigned primary care provider. The conditions represented in the registries thus far include asthma, congestive heart failure (CHF), diabetes (DM), and hypertension (HTN). The registries contain clinical information, such as blood pressure, last appointment date, and glycolated hemoglobin or A1C. This clinical information, which can be sorted, reflects current data that has been entered into the EMR. For example, a report can be generated with a list of all the DM patients who see a certain provider, sorted by those with the highest A1C’s and the last appointment date. These registries are organized and ‘worked’ by the care coordinator according to quality-driven protocols. The patients who meet protocol criteria, for example, the need to visit the clinic, are contacted and encouraged to re-engage with their care team. Patients who are in need of further assistance managing their chronic disease are encouraged to meet with the care coordinator. This care coordinator coaching visit will be detailed in the next section. The shared EMR for tracking patient transitions and the chronic disease registry reports provide the care coordinator with the necessary tools for population management.

Achieving NCQA’s Level 3 Recognition

The fourth strategic initiative focuses on achieving NCQA’s Level 3 recognition for all primary care practices. It parallels our organization’s vision, namely, “to provide the best possible outcome for every patient by bringing doctors together in an accountable medical group” (Carilion Clinic, n.d.). To achieve Level 3 certification a clinic must satisfy all the ‘must pass’ elements in the NCQA standard and reach a score of 75 out of 100 possible points (NCQA, 2011b). This level of certification maximizes all aspects of patient-centered support services and is the most promising initiative for enhanced reimbursement.

One support service, now delivered in the practice sites that have achieved the Level 3 recognition, is ‘self-management support’ in the form of disease coaching. The NCQA standard for medical home certification recommends providing self management support to patients with chronic diseases. In this process patients with poor disease control are identified, either by the disease registry or during the care-team huddle. These patients are given the opportunity to connect with the nurse care coordinator. At this encounter the nurse explores patients’ understanding of their condition and any barriers they may have interfering with disease control. A care plan is formulated and each patient establishes an achievable, self-management goal. Finally, the patient is asked to rate how confident they are in achieving the goal set. This visit data is captured in the EMR through template documentation, including the patient’s goal along with their confidence score. This visit data reflects the true intent of the NCQA medical home standard. These interactions are some of the most satisfying for Carilion’s current care coordinator nurses.

Finally, the patient is asked to rate how confident they are in achieving the goal set. This new, ambulatory nursing care coordinator role is a win-win situation for both patients and nurses. Nurses experience a sense of professionalism not previously seen in typical ambulatory practices, while the patients have reported improved safety and satisfaction. In the Geisinger Health System a similar nursing position has already notably improved patient outcomes (Whelan & Russell, 2009). As of this writing, Carilion has provided this advanced level of primary care in eleven of it practices, each of which has been certified as a level-3 medical home. Six practices are currently under evaluation, and more certified practices are on the horizon.

Participating in Medical Home Research

Finally, Carilion Clinic’s fifth initiative is participating in medical home research. The research has two objectives: one is to identify improved patient outcomes in various primary care settings and the second is to identify approaches that will ensure sustainability of the medical home model. Preliminary patient outcomes show improved disease control and an increase in patient completion of their preventive care measures in all of the medical homes practices.

We are looking to the future by innovating within, sharing these efforts with other health systems, and participating in market research. The aforementioned ACO Pilot Project is led by the Engelberg Center for Health Care Reform at the Brookings and The Dartmouth Institute for Health Policy and Clinical Practice (Carilion Clinic, 2009). According to Carilion’s press release, this pilot project aims “to implement and test a replicable model that can be used nationwide. During the project participating pilot sites will negotiate, implement, and refine the ACO model in their regions in a multi-payer, multi-stakeholder environment” (Carilion Clinic, 2009).

Evaluation Efforts to Date

Nursing-focused pilot studies are also underway. Ambulatory workflows are being examined around the duties of the nurse care coordinators. At present a single care coordinator is supporting two small-sized practices. The workflows around these two sites are under evaluation. A chronic disease certification program is being developed for the nurse care coordinators. Additionally, the medical home certified sites share best practice ideas monthly in an ongoing effort to provide patient-centered care in various formats. One example of nontraditional care that is being explored is that of group medical visits in which a group of patients with the same chronic condition share a medical appointment. This one- or two-hour long appointment time is spent with patients interacting with other patients learning disease control strategies and sharing time with their care team assessing their personal plan of care.

Carilion is also working with staff at Virginia Polytechnic Institute and State University (Va-Tech) to conduct medical-home research. New healthcare legislation has called for the Centers for Medicare and Medicaid Services to create an Innovation Center to facilitate delivery-system changes. The Innovation Center is charged with “testing innovative payment and service-delivery models designed to reduce Medicare and Medicaid expenditures while preserving or enhancing the quality of care” (Mechanic & Altman, 2010, p.772). Two sectors of Va-Tech have joined with Carilion to move the PCMH concept forward. First, the Economics Department is analyzing viable economic models for PCMH implementation and sustainability; and second, the Virginia Tech - Arlington Center for Health Informatics and Systems is working on home health and mental health extensions of service. This work responds to the call for action noted in the new legislation, the Patient Protection and Affordable Care Act (Arvantes, 2011).

Limitations of the Model

The independent provider has little incentive to spend considerable time on this process with no up-front or immediate financial gain...payment reform is essential to transform and deliver the required care of the PCMH model. Independent primary care offices may find the current medical home transformation process quite challenging. The primary care workforce is small and the work is reimbursed primarily on volume. Dedicating time to ongoing quality improvement in numerous areas, such as managing patient care transitions, facilitating ongoing quality improvement processes, and providing expanded patient support services, none of which are currently reimbursed, is not possible with the current staff in most primary care offices. The additional salary for a nurse to perform the care coordinator function(s) is not feasible for most office budgets. Finally, without an EMR it is very difficult to achieve certification as a medical home and sustain this level of care. Many hours must be dedicated to this process, including chart reviews and generating reports. The independent provider has little incentive to spend considerable time on this process with no up-front or immediate financial gain.

However, large health systems, such as Carilion, and also groups of physicians are responding to this “bold movement designed to improve quality of care while controlling costs and accommodating a larger patient base” (Kuzel, 2010, para. 3). In the absence of a formal reimbursement model these changes may be unsustainable. There is early evidence that patient-centered efforts, such as disease-management programs, result in significant savings among Medicaid populations (Jaspen, 2010). It is generally understood, that it is cheaper to prevent or closely manage a disease than to pay for its complications. Unfortunately, few of those who are delivering this level of coordinated and comprehensive care are receiving financial support. A recent four-year, national-demonstration project of practice redesign work was completed by Transformed (Backer, 2010). ‘Transformed’ is a subsidiary of the American Academy of Family Physicians. The organization works with primary care offices as they use resources and consultants to transform themselves to the new, patient-centered model with the goal of improving both patient and professional satisfaction (Transformed, n.d.). The demonstration project results, noted by Backer (2010), indicate that payment reform is essential to transform and deliver the required care of the PCMH model.


Patient-centered care has become the expectation for those served by and working for our organization. There are large variances in both cost and quality of the healthcare delivered across the United States. The latest healthcare reform proposes dedicating more resources to primary care. The hope is that with these resources primary care will be able to improve the level of coordinated care and thus contain costs. In the seven Joint Principles, healthcare leaders challenge healthcare providers to deliver patient-centered care as the norm, while simultaneously requesting payments that reflect these expanded services. The National Committee on Quality Assurance provides an objective scoring tool, the Physician Practice Connections® - Patient-Centered Medical Home standard, for certifying medical homes and capturing these expanded services. Carilion Clinic, like other early adopters, has begun the transformation to an accountable care organization by adopting the PCMH model in all their primary care practices. The organization hopes to be well positioned as reform continues to evolve.

Patient-centered care has become the expectation for those served by and working for our organization. This is a very exciting time in ambulatory nursing. The patient-centered model with its whole-person focus features quality and safety while using a team approach in these redesigns efforts. Carilion is part of a number of collaboratives currently working with industry leaders on various redesign efforts. The Patient-Centered Primary Care Collaborative (PCPCC), a multi-stakeholder organization of over 500 members from industry and medicine, continues to convene and support the PCMH redesign work. These innovative efforts of many groups are leading the US toward making the vision of high quality healthcare a reality.


M. Colette Carver, MSN, APRN-BC-ADM, FNP

Colette Carver is a Team Leader at Carilion Clinic, based in Roanoke, VA. Her current focus is the implementation of the Patient-Centered Medical Home Model for the Clinic. After receiving her MSN from Duke University in Durham, NC, she joined the Duke Family Medicine staff where she participated in such performance improvement projects as Advanced Access Scheduling, Office Redesign Strategies, and the Community Care of North Carolina Project. She has been actively involved in health education, as a former instructor for the University of Pennsylvania in Philadelphia, as a Diabetes Educator, and as a preceptor for nurse practitioner students. Currently, she is working for Carilion Family Medicine in Vinton, VA, where she has been instrumental in their gaining certification as the first Level-3 Patient-Centered Medical Home in the state. She continues to strengthen care coordination at Carilion Clinic as all primary care practices are in the process of being transformed to the new Patient-Centered Medical Home Model.

Anne T. Jessie, MSN, RN

Anne Jessie currently serves as Practice Manager for the Carilion Clinic faculty practices of Internal Medicine, Rheumatology, Gastroenterology, and Hepatology. As the Lead Practice Coordinator implementing the Patient-Centered Medical Home Model for Carilion Clinic Internal Medicine, she is applying systems engineering to address the unique challenges presented by a faculty medicine practice. Upon receiving her Master’s degree in Nursing Leadership from Jefferson College of Health Sciences in Roanoke, VA, Anne’s focus has been to define and implement a shared governance structure for ambulatory nursing within Carilion Clinic. In addition, she has been involved in the standardization of ambulatory nursing competencies and practices. Anne’s career goal is to contribute to the development of nursing practice in the ambulatory setting.


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© 2011 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2011

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