Program Goals

In support of The Commonwealth Fund’s efforts to promote delivery system improvement and innovation, the Program on Patient-Centered Coordinated Care sponsors activities aimed at improving the quality of primary health care in the United States, including efforts to make care more centered around the needs and preferences of patients and their families. To achieve this mission, the program makes grants to:

• strengthen primary care by promoting the collection and dissemination of information on patients’ health care experiences and on physician office systems and practices that are associated with high-quality, patient-centered care;
• assist primary care practices with the adoption of practices, models, and tools that can help them become more patient-centered and coordinate more closely with hospitals, specialists, and other public and private health care providers in their communities; and
• inform the development of policies to encourage patient- and family-centered care in medical homes.

The Issues

As defined by the Institute of Medicine, patient-centered care is "health care that establishes a partnership among practitioners, patients, and their families ... to ensure that decisions respect patients’ needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care."

There is substantial evidence that health systems that have a strong primary care foundation deliver higher-quality, lower-cost care overall and greater equity in health outcomes. Research also shows that patient-centered primary care is best delivered in a medical home—a primary care practice or health center that partners with its patients in providing enhanced access to clinicians, coordinating health care services, and engaging in continuous quality improvement.

Recent Projects

Promoting and Evaluating the Patient-Centered Medical Home
In April 2008, The Commonwealth Fund launched the five-year Safety Net Medical Home Initiative to support the transformation of primary care clinics serving low-income and uninsured people into patient-centered medical homes. Led by Jonathan Sugarman, M.D., president and CEO of Qualis Health, a nonprofit quality improvement organization based in Seattle, and Ed Wagner, M.D., of the MacColl Institute for Healthcare Innovation, the initiative involves 65 clinics in five states: Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. The Qualis/MacColl team is providing technical assistance to local quality improvement organizations that, in turn, are helping the clinics achieve benchmark levels of performance in quality and efficiency, patient experience, and clinical staff experience. Eight foundations have joined The Commonwealth Fund in support of the initiative. To extend the reach and impact of the Safety Net Medical Home Initiative, the project team is developing a Web-based national curriculum for quality improvement coaches to support the nation’s 1,300 community health centers in becoming effective medical homes.

Under another Fund grant, Marshall Chin, M.D., and a team of researchers at the University of Chicago are evaluating whether clinics participating in the Qualis/MacColl initiative are in fact able to make the changes necessary to function as medical homes. The team is also assessing the extent to which sites receiving technical assistance and enhanced reimbursement for providing medical home services improve their performance on measures of quality, efficiency, patient experience, and clinician or staff satisfaction. While data on patient impact is not yet available, baseline results of physician and clinic staff surveys show that when a safety-net clinic has more core medical home features—systems for tracking patients with unmet needs, personnel to help patients manage their chronic conditions, resources for quality improvement—the physician and clinic staff report higher morale and greater satisfaction with their jobs.

Given the large number of medical home evaluations the Fund is supporting, The Commonwealth Fund established the Patient-Centered Medical Home Evaluators’ Collaborative, cochaired by Meredith Rosenthal, Ph.D., and Melinda Abrams, to align evaluation methods, share best practices, and exchange information on ways to improve evaluation designs. A key objective of the collaborative is to reach consensus on a core set of standardized measures in each of the key areas under investigation, such as care utilization, cost savings, clinical quality, patient experience, and clinic staff experience. In an August 2010 article in Medical Care Research and Review, Rosenthal and colleagues provided recommendations for measuring changes in utilization and costs in medical home evaluations. Information about the collaborative and its progress can be found on the Fund’s Web site.

Building Capacity for Delivering Patient-Centered Coordinated Care
The Commonwealth Fund also is supporting efforts to improve the measures by which primary care practices achieve accreditation as medical homes, with a particular focus on making the measures more patient- and family-centered. In 2006, the Fund supported the National Committee for Quality Assurance (NCQA) in its work with the nation’s leading primary care specialty societies to develop criteria for assessing and recognizing practices as medical homes. As of November 2011, at least 15,000 clinicians at more than 2,900 primary care practices have officially been recognized as patient-centered medical homes. Under a subsequent grant, Sarah Scholle, Dr.P.H., and her colleagues at NCQA developed and tested additional criteria for recognition based on patients’ experience, including the quality of patient–clinician communication, patient self-management, and care coordination. The new medical home standards were released in January 2011.

Helping Smaller Physician Practices Share Patient Care Resources
Because of their limited resources and capacity, smaller independent physician practices often struggle to meet all the functional requirements of a medical home, from providing round-the-clock patient access to using a team approach to chronic disease management. Research has shown, however, that when primary care providers in the same community band together to share local resources, such as quality improvement coaches or care coordinators, they can enhance their capacity and improve performance. With Commonwealth Fund support, Ann S. O’Malley, M.D., of the Center for Studying Health System Change (HSC) is identifying primary care sites that jointly provide after-hours coverage, helping patients avoid trips to the emergency department. Her research team is preparing cases studies of these physician practices to provide guidance for other practices looking to replicate effective models.

Another HSC team, led by Emily Carrier, M.D., is exploring how independent primary care practices develop and implement agreements with specialists, hospitals, and nursing homes to coordinate care for the patients they share. The findings could aid in the development of accountable care organizations and bundled-payment systems that are predicated on well-coordinated care. Also under study is the potential of shared patient panel management, which involves identifying and reaching out to patients with chronic illness who are overdue for office visits as well as patients requiring follow-up treatment with a specialist.

Improving Policy and Financing to Promote Patient-Centered Care
Forty-one states are developing patient-centered medical home programs for their Medicaid and Children’s Health Insurance Program enrollees. With Commonwealth Fund support, Neva Kaye and Mary Takach of the National Academy for State Health Policy (NASHP) are working with state Medicaid officials to ensure beneficiaries have access to a medical home. In 2009, NASHP assisted eight states—Alabama, Iowa, Kansas, Maryland, Montana, Nebraska, Texas, and Virginia—with creating incentives and payment models that encourage primary care sites to become medical homes, helping new medical homes obtain official certification, and developing measurement strategies to monitor and evaluate quality and cost outcomes statewide.

In 2011, NASHP launched its third Medicaid medical home consortium to help up to 17 states strengthen, expand, and sustain medical home initiatives that they previously established. Additionally, the NASHP team is developing a new policy curriculum to inform federal officials about the states’ experiences. In a July 2011 Health Affairs article, NASHP’s Mary Takach noted the promising early results of recent state policies centered on medical home qualification and payment, including improved access to care, quality, and cost control. For more information about states’ efforts to promote medical homes, view NASHP’s interactive medical home map or download the Commonwealth Fund/NASHP report, Building Medical Homes: Lessons from Eight States with Emerging Programs.

To identify the most effective way to reimburse primary care providers that attain high performance, the Pennsylvania Chronic Care Initiative—the most extensive multipayer medical home demonstration program in the nation—is testing four different models for financially rewarding primary care sites that function as patient-centered medical homes. A Fund-supported team of RAND and Harvard University researchers headed by Mark W. Friedberg, M.D., is assessing the differential impact of these payment approaches—which range from per-member per-month care management fees to shared savings—on health care utilization, efficiency, cost, and quality of care.

Future Directions

The Affordable Care Act includes a number of provisions intended to strengthen primary care in the United States. To aid successful implementation of these reform efforts, The Commonwealth Fund’s Program on Patient-Centered Coordinated Care will support projects in a number of areas.

Making medical homes successful. To help the spread of medical homes, health system leaders, clinicians, and policymakers need information on the factors that lead to improved efficiency and lower costs. Under a Commonwealth Fund grant, a team of researchers at Pennsylvania’s Geisinger Health System is studying how its organization’s medical home program is achieving reductions in costly hospital admissions and readmissions. dditional Fund-supported analyses will examine effective ways to streamline and standardize implementation of medical homes in primary care sites.

Resource-sharing. Owing to their limited resources, smaller independent physician practices typically are unable to deliver the breadth of services and engage in the range of quality improvement activities that are more common in larger practices. The Fund is supporting research into effective models for sharing clinical support services and health information systems that enable practices to provide coordinated care, after-hours appointments, and other services expected from medical homes. For example, Tara Bishop, M.D., and Lawrence Casalino, M.D., at Weill Cornell Medical College are evaluating a pilot program in New York City in which safety-net practices will share the services of a patient-panel manager, who helps ensure patients receive recommended routine services and chronic disease care.

Policy implementation. As the Affordable Care Act’s primary care provisions take effect, a Commonwealth Fund priority will be to share early lessons from the field with local, state, and federal policymakers to help ensure full advantage is being taken of the opportunities provided in the legislation. For example, with Fund support, NASHP staff will work with a select group of states on creating "health homes" (medical homes) for care of patients with chronic illness.

Improving care coordination. Commonwealth Fund support is aiding efforts to identify and assess promising models for improving information-sharing among primary care clinicians and specialists, hospitals, and other providers in both safety-net and commercial settings. One such project, led by Timothy Ferris, M.D., at Massachusetts General Hospital, is comparing successful primary care–based care management programs, which have been shown to improve quality of care and health outcomes for high-risk patients as well as reduce per capita expenditures.

To apply for a grant from The Commonwealth Fund’s Patient-Centered Coordinated Care program, visit Applicant and Grantee Resources.