Contact: Kathryn Phillips, kathrynp@qualishealth.org    

Sponsored by The Commonwealth Fund, in collaboration with eight co-funders, The Safety Net Medical Home Initiative is a five-year demonstration project designed to help 65 community health centers in five states transform into patient-centered medical homes.

Health centers in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania—each of which partnered with 10 to 15 safety-net clinics in their state—are receiving technical assistance, training, and ongoing support in order to improve how they deliver care to patients, including better coordinating care, enhancing access to care, improving doctor–patient interactions, and implementing quality improvements. The health centers also receive funding to support a medical home facilitator who leads clinic-based quality improvement projects and other activities.

Launched in April 2008, the initiative is led by Qualis Health, a Seattle-based quality improvement organization, to provide support to the states and health centers to improve quality of care. Working closely with the MacColl Institute for Healthcare Innovation, Qualis Health supports health centers’ efforts to become medical homes. The Qualis/MacColl team has identified eight "change concepts," which serve as the framework for its curriculum:

• Empanelment
• Continuous and Team-Based Healing Relationships
• Patient-Centered Interactions
• Engaged Leadership
• Quality Improvement (QI) Strategy
• Enhanced Access
• Care Coordination
• Organized, Evidence-Based Care

The Qualis/MacColl team is currently developing implementation guides on these concepts to help the clinics improve access, coordinate care, and engage patients better. It also is helping several participating clinics achieve National Committee for Quality Assurance recognition as medical homes. In addition, the team has developed a new assessment tool, the Patient-Centered Medical Home Assessment to monitor health centers’ readiness and improvement over time.

An evaluation of the initiative is being led by Marshall Chin and colleagues at the University of Chicago.

It is anticipated that at the end of the initial grant period, all 65 health centers will achieve benchmark levels of quality, efficiency, and patient experience. Yet, the aim of this multi-pronged initiative is not only to transform these health centers into medical homes, but also to promote policy options to ensure that the model is sustained and spread throughout each state. The ultimate goal is for all community health centers in all 50 states to adopt the medical home model.

A compilation of tools, archived webinars, and issues of the Medical Home Digest are available on the initiative's Web site.

Recent Products and Publications

NEW:  Implementation Guides

1.  Engaged Leadership
   a. Strategies for Guiding PCMH Transformation From Within
2. Empanelment 
   a. Establishing Patient-Provider Relationships
   b. Assigning and Managing Panels in a Patient-Centered Medical Home
3. Continuous and Team-Based Healing Relationships 
   a. Improving Patient Care Through Teams
   b. Elevating the Role of the Medical/Clinical Assistant: Maximizing Team-Based Care in the Patient-Centered Medical Home
   c. Redefining Staff Roles: Where to Start
4. Patient-Centered Interactions 
   a. Patient-Centered Interactions Part 1: Measuring Patient Experience
   b. Patient-Centered Interactions Part 2: Engaging Patients in their Health and Health Care
   c. Patient-Centered Interactions Part 3: Communicating to Improve the Patient-Centered Experience
5. Quality Improvement Strategy 
   a. Quality Improvement Strategy Part 2: Optimizing Health Information Technology for Patient-Centered Medical Homes
   b. Optimizing Health Information Technology for Patient-Centered Medical Homes
6. Enhanced Access 
   a. Enhanced Access: Providing the Care Patients Need, When They Need It
7. Care Coordination 
   a. Care Coordination: Reducing Care Fragmentation in Primary Care
   b. Strategies to Reduce Avoidable Emergency Department Use
8. Organized, Evidence-Based Care 
   a. Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations
   b. Improving Care for Complex Patients: The Role of the RN Care Manager

Patient-Centered Medical Home Assessment (PCMH-A). This survey is designed to help systems and provider practices move toward the "state-of-the-art" in delivering patient-centered care in the context of a medical home. The results can be used to help your team identify areas for improvement.

Issue Briefs: Paying for the Medical Home: Payment Models to Support Patient-Centered Medical Home Transformation in the Safety Net and Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act (October 2010).  These publications provides an introduction to a series of policy briefs focusing on payment reform opportunities to support and sustain the medical home.

The Medical Home Digest. A newsletter devoted to providing information about medical home transformation in the safety net.

The Commonwealth Fund is joined in support of the project by eight co-funders, including the Colorado Health Foundation
(www.coloradohealth.org ), Jewish Healthcare Foundation (Pittsburgh) ( www.jhf.org ), Northwest Health Foundation (Portland, Oregon)
(www.nwhf.org ), Partners HealthCare (Boston) ( www.partners.org ), The Boston Foundation ( www.tbf.org ), Blue Cross Blue Shield of Massachusetts Foundation ( www.bcbsmafoundation.org ), Blue Cross of Idaho Foundation for Health ( www.bcidahofoundation.org ), and Beth Israel Deaconess Medical Center (Boston) ( www.bidmc.org ).