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As a next step in PCMH model evolution, we see progressive organizations beginning to expand their focus outward from the PCP office, building connections and partnerships with specialists as ongoing collaborators in patient care. But achieving perfect PCMH-specialist collaboration will not be easy--especially for less-integrated organizations--as there are a number of sizeable barriers in the way.
In a series of blog posts across the next month, we will take a look at the path forward, focusing on each of the major PCMH-specialist barriers in turn.
Role of specialists in the medical home: Part I
The proposed rule for the Medicare Shared Savings Program provides an initial roadmap for how providers could be reimbursed by Medicare as accountable care organizations (ACOs). Reading the rule from a medical home perspective, we see strong reinforcement of the importance of the medical home model in achieving shared savings goals. The rule also points the way toward future direction of PCMH model evolution--for example, by updating and expanding the CMS definition of "patient-centeredness" and laying out some objectives that even the most advanced PCMHs will have to stretch to meet.
New Shared Savings Rule: PCMH Implications
Why Risk-Stratifying is Important
Ability to risk-stratify patients is one of the major differences between beginning and advanced PCMHs. While beginning PCMHs have their hands full just establishing a patient/disease registry, identifying patients with target conditions, and flagging gaps in care, the more advanced PCMHs are able to sort patients into high, moderate, and low-risk categories. (Note -- for all practical purposes, "risk" here means "risk of hospital admission").
Risk-Stratifying Patients - Two Example Approaches