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MaineHealth/MMC PHO 
     Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) is a team-based model
of providing care in a coordinated, consistent and efficient way. 
Providing patients the best care when and where they want it requires
teams to actively look for improvement possibilities and opportunities to
create efficient work flow, satisfied staff and effective communication
with patients and other providers. 
Explore our site for information about:
-MaineHealth/MMC PHO Learning Collaborative 
-NCQA and other Training Opportunities for practices 
-Patient centered healthcare Resources from around the country
-Improvement Coaching and Practice Improvement Tools

News and Information

2014 PCMH Evidence

Over the last few months the body of evidence for Patient Centered Medical Home (PCMH) has continued to expand and the U.S. Department of Health and Human Services (HHS) has announced its commitment to alternative payment and innovative care delivery models along with its goals towards more comprehensive payment reform. A brief summary of the evidence and highlights of payment reform follow.

Evidence: A study by the Patient-Centered Primary Care Collaborative (PCPCC) and Milbank Memorial Fund analyzed 28 academic studies, industry reports and state government evaluations. Based on its 2015 report PCMH has been found to reduce healthcare costs, and unnecessary utilization of services, improve population health and preventive services, increase access to primary care and create satisfaction among patients and clinicians.

CMS’s Innovation Center released the first year findings of two programs. The Comprehensive Primary Care Initiative findings suggest that the greatest overall transformation has been in hospital readmission rates (2% decrease) and emergency department visits (3% decrease) with the bulk of its total saving generated from patients in the highest risk quartile. The initiative includes 492 practice sites with 2,158 providers that serve approximately 2.5 million patients. It is important to note that the CPC initiative’s service delivery and payment models have been CMS defined while the CMS Multi-payer Primary Care Practice Demonstration models have been defined individually by the states participating in the program. Only two states have noted a reduction in the growth of Medicare spending resulting in an inconclusive evaluation at this time. It was also suggested that sustained funding streams may be necessary to allow practices enough time to “deepen and refine their methods” and to sufficiently collect and act on data. The MAPCP project represents 700 practice sites with 3,800 providers serving approximately 2.6 million patients. All three of these studies have been attached for your review.

Payment Reform: Finally, the U.S. Department of Health and Human Services (HHS) announced its commitment to alternative payment model such as Accountable Care Organization (ACOs) or bundled arrangements as well as innovative care delivery models, like Patient Centered Medical Home (PCMH) signifying a positive shift in payment reform policy that moves away from the traditional fee for service (FFS) system. HHS has set measurable goals and a timeline to move the Medicare program and the health care system at large, toward paying providers based on quality, rather than quantity of care they give patients. Additionally CMS has set a goal of tying 30 percent of traditional Medicare payments (based on Fee-For Service) to quality or value through these alternative payment models by 2016 and 50 percent by 2018.

2014 NCQA Standards Are Available

Key Changes Include:

    • Enhanced emphasis on team-based care
    • Care management focus on high-need populations
    • Aligning of quality improvement with the triple aim
    • Sustained transformation
    • Integration of behavioral health

For more information, visit NCQA's PCMH page or click below for a
NCQA Standards Crosswalk 2011 to 2014

Additional 2014 PCMH Resources

MaineHealth and The MMCPHO have created a Checklist in alignment
with NCQA 2014 Standards. Adapted from previous CCNC versions, this
checklist enables practices to track progress toward recognition.
Click here to view

The Community Care of North Carolina (CCNC) website has great resources
for practices looking at NCQA recognition including a summary of PCMH
scoring and an overview of the 2014 standards.

Wave 5 PCMH Learning Collaborative

Wave 5 of our PCMH Learning Collaborative kicked off on January 14th.
We are proud and excited to welcome eight more teams!

-Stockton Springs Regional Health Center
-Lincolnville Regional Health Center
-Donald S Walker Health Center
-Robert Merrill, MD / Family Medicine
-Primary Care at Memorial Hospital
-SMHC Internal Medicine Kennebunk
-St. Marys Medical Associates
-SMHC - Sanford Internal Medicine

Please click here for more information

Patient Centered Medical Home
Work In Progress - Video

Dr. Kate Herlihy, Western Maine Pediatrics, describes the tools and
techniques the practice has used as part of their transformation process.
Click here to view the 3 minute video.

Quick glance at improvement tools -
Institute for Healthcare Improvement
Open School:

These short videos offer instruction on improvement tools using visual
examples. Taught by Robert Lloyd, Director of Performance Improvement
at IHI.


Visit our Resources page for information on PCMH initiatives and
sources including Safety Net Medical Home Initiative, TransforMED
and Maine Quality Counts.

We also provide a Training Opportunities page listing available webinars
and in-person educational sessions designed to help practices build
quality improvement, Medical Home, and NCQA recognition knowledge. 


110 Free Street | Portland, Maine 04101 | (207) 661-7001