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Loving Our Neighbors through Systems

What is PCMH?

Serving a population with multiple and challenging health care needs and with limited access to health resources can feel like putting a proverbial finger in the dam, such that building a better dam becomes a seemingly insurmountable task. Frustration or exhaustion from daily work demands can blunt idealism, leading to burnout, pessimism, or compromise on mission. The system is far from perfect, and health centers’ continual focus on meeting patients’ presenting health needs leaves little to invest in quality improvement. The patient-centered medical home (PCMH) model both affirms the idealism of what primary care ought to be and outlines a structured path of how to get there. This article analyzes the PCMH model, its special relevance to Christian health centers, and a promising case study.

The idea of a medical home was first developed in pediatrics in the 1960s as a place to physically house the medical record for children with complex medical needs. Not surprisingly, caring for everybody with the love and coordination required for children with special medical needs is good for all patients. In the last ten years the idea has been generalized to include broader principles of patient-centered care. Recently it has gained significant support from the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, and the government as the future of primary care. Early research suggests the PCMH model yields positive effects on quality, patient experience, and provider experience, with mixed results on costs; while calling for better evidence, the Agency for Healthcare Research and Quality concludes that the PCMH model is a promising innovation, especially as it continues to be refined [1].

The PCMH model defines high-quality primary care in the 21st century with the patient at the center. The focus of a doctor in a PCMH is the relationship with the patient expressed in physician-led, team-based care for the whole person over time. A PCMH reaches beyond individual clinical encounters to intentionally improve access and quality of care, to utilize electronic records and communication tools, and to effectively coordinate care. Ultimately, the model’s goal is to enhance health care organizations’ service of their patients and their local community with quality, evidence-based care.


Secondly, the PCMH model is a framework and accountability structure to empower health centers to provide higher quality and more cost effective primary care. Government agencies have selected the National Committee on Quality Assurance’s (NCQA) PCMH 2011 Standards as the preferred accreditation metrics. The six NCQA PCMH 2011 Standards are: (1) enhance access and continuity; (2) identify and manage patient populations; (3) plan and manage care; (4) provide self-care support and community resources; (5) track and coordinate care; and, (6) measure and improve performance [2]. The NCQA PCMH 2011 Standards include a scoring system which highlights certain elements as “must pass” and certain factors as “critical,” targeting improvement efforts to areas vital to patient-centered care with established methods for improvement. Packaging these six broad standards together under one recognition program promotes comprehensive competency in patient-centered care.

One of the most important features of the PCMH model is its incorporation of external and widely accepted public standards. Evaluation itself is an opportunity for self-reflection by helping health centers identify their current practices and then think intentionally about how they can implement process improvement. Submitting to outside standards can challenge existing beliefs that current practices are sufficient and provide a measure of honest accountability that can be difficult to attain internally when the gap between present reality and ideal design makes compromise tempting. Also, adherence to shared standards allows health centers to learn from others’ experiences of what is possible and to identify key problem areas without hiring outside consultants.

Christian Health Centers

Christian health centers share many of the values central to patient-centered medical homes. Being patient-centered is motivated by a desire to love patients as neighbors, as in Matthew 22:37-39. Christians advocate that health encompasses the whole person’s physical and spiritual needs. Christian health centers have a special mandate to represent Christ by the quality of their service, and Christian health centers in underserved communities play a special role expressing Christ’s love for the poor. By adopting the patient-centered medical home model, Christian health centers have a great opportunity to set an example of truly patient-centered care that is wise at the individual patient, community, and systemic levels.

Christian health centers are important participants in the complex and evolving U.S. health care system. The PCMH model is widely seen as the future of primary care in the U.S., with many of its components becoming common practice. Electronic health records are becoming the norm with recent changes in Medicare and Medicaid reimbursement requiring meaningful use of an electronic health record. Reimbursement will increasingly depend on electronic documentation and reporting of quality measures. Practices that cannot electronically communicate with their “medical neighborhood” will eventually be left out. Care coordination and chronic disease management are becoming the responsibility of primary care practices. As nurse practitioners do increasingly more primary care, functioning as team a team enhances a health center’s ability to provide affordable, comprehensive care. The PCMH standards provide a rubric to help primary care practices keep up with the pace of changes to come. Christian health centers must be willing to adopt these technical changes to remain practically relevant and financially solvent.

A Case Study: Esperanza Health Center

To make this more concrete, we will examine a case study: Esperanza Health Center in Philadelphia. Esperanza Health Center is a Christian, bilingual Federally-Qualified Health Center (FQHC) that serves North Philadelphia's Latino community. In 2011, Esperanza served over 7,300 patients through approximately 35,900 patient visits. Esperanza Health Center has more than doubled in patient volume in the last five years, and has recently opened its third location to double again in capacity over the next few years. Esperanza’s assets include a committed leadership team, a growing team of new and experienced clinicians, a stable balance sheet, and five years of electronic health record experience. Esperanza does many things well in serving its patients, but still faces many challenges common to urban underserved health centers.

Esperanza Health Center is participating in Medicare’s Federally-Qualified Health Center (FQHC) Advanced Primary Care Demonstration, which began in 2011 and will continue through 2014. This project is administered by the Health Resources and Services Administration (HRSA). Participation in the FQHC Advanced Primary Care Demonstration means that Esperanza is committed to becoming recognized as the highest-level PCMH, which will require significant practice transformation over the next three years. Esperanza’s philosophy and priorities match well with the values inherent in the NCQA Standards, so Esperanza will not require dramatic organizational culture change to become a PCMH. Instead, the PCMH model offers health centers and other primary care providers a roadmap for quality improvement and a measurable tool to monitor progress.

In the baseline evaluation that was required to apply to the Advanced Primary Care Demonstration, we identified a number of key areas where improvements will allow Esperanza to meet NCQA standards, become more patient-centered, and provide higher quality care. One particular focus area for Esperanza is improving patients’ access to their personal clinician. For some veteran clinicians (who have fewer clinic days due to increased administrative responsibilities), the wait for a routine appointment can be as long as two to three months. Esperanza recognizes that patients need access to their clinicians in order to receive primary care, but this problem of long waiting times for appointments persists. Esperanza has experimented with various options to improve patient access, including having a triage doctor conduct urgent patient visits and setting aside triage slots. These changes have improved access for acute visits, but more dramatic changes to patient panels or the health center’s overall scheduling system that improve access for routine appointments will be required to meet the NCQA standards. Because the NCQA standards identify patient access as critical to the success of a medical home, Esperanza has an additional incentive to devote resources to fix this well-known problem and, importantly, a clear deadline. By addressing this problem, Esperanza’s patients will have better access to their clinicians when they need them.

To meet other standards will require crucial yet less dramatic efforts, including documentation of current practices, development of clinic policies, development of EHR templates, expansion of current efforts in disease management from diabetes to other key chronic conditions, and other incremental improvements. Together, these efforts will help Esperanza take tangible steps to make its systems better for its patients. By working to implement quality improvement processes within the health center and demonstrating that measurable improvements are possible, becoming a certified as a PCMH has the potential to yield significant benefits for Esperanza’s patients over time, even beyond the official standards.


The patient-centered medical home model is not a magic cure-all for all of the many challenges now facing Christian health centers, but rather a structured commitment and plan to tackle problems that commonly prevent health centers and other primary care providers from providing patient-centered care. For health centers that share the values embedded in the PCMH model, as many Christian health centers do, becoming a PCMH provides a framework to build systems which enable better care for patients. The patient-centered medical home model is not only an impressive way to practice medicine in our time; it is also an amazing new tool we can use to love our neighbors in the communities we are called to serve.

[1] Peikes D, Zutshi A, Genevro J, Smith K, Parchman M, Meyers D. Early Evidence on the Patient-Centered Medical Home. Final Report (Prepared by Mathematica Policy Research, under Contract Nos. HHSA290200900019I/HHSA29032002T and HHSA290200900019I/HHSA29032005T). AHRQ Publication No. 12-0020-EF. Rockville, MD: Agency for Healthcare Research and Quality. February 2012.

[2] Edgman-Levitan S et al. NCQA’s Patient-Centered Medical Home (PCMH) 2011. National Committee for Quality Assurance. January 31, 2011.

Matt Durstenfeld is a medical student at the Perelman School of Medicine at the University of Pennsylvania and a leader of the Penn Med Christian Fellowship. He studied biomedical engineering at Yale University, where he became interested in health care management after doing public health consulting in Ghana. In the summer of 2011, he did a management internship at Esperanza Health Center, successfully gaining a spot for Esperanza in Medicare’s Advanced Primary Care Demonstration and winning a HRSA grant for initial costs.

The patient-centered medical home (PCMH) model both affirms the idealism of what primary care ought to be and outlines a structured path of how to get there. This article analyzes the PCMH model, its special relevance to Christian health centers, and a promising case study.