Systems of Care/Patient-centered Medical Home Initiative

Initiative overview

The Colorado Medical Society has partnered with the primary care societies in Colorado to further the adoption of medical home models.  The System of Care/Patient Centered Medical Home (SOC/PCMH) Initiative is a two year grant program, generously funded by the Colorado Health Foundation, that seeks to improve systems of care by supporting physicians in becoming medical homes and working with specialists to uplink medical homes into integrated medical neighborhoods.  The objective of the initiative is to develop strategies, provide education and technical assistance to enable Colorado physicians to make informed decisions about their participation in medical home models. 

So what is a patient-centered medical home? What is a medical neighborhood?

A patient-centered medical home is led by a personal physician who works with patients and the care team to coordinate all health services in a quality, cost-effective and accessible manner. Learn more about the model and the latest evidence showing its effectiveness. A medical neighborhood fosters shared accountability by linking specialty care and primary care physicians together to provide integrated, patient-centered care.

Self-paced resources for pursuit of PCMH

The SOC/PCMH initiative has a number of resources that can help you learn more about becoming or linking to a medical home. Learn more now. 

Free technical assistance

Are you interested in becoming or linking to a patient-centered medical home? The initiative offers physicians free technical assistance including: small or large group presentations, one-on-one office visits, Parade of Homes tours, mentoring and rapid improvement activities.

Contact Chet Seward at 720-858-6314 to learn more.

Primary care-specialty care compact

The SOC/PCMH initiative has developed a care compact. The purpose of the compact is to improve care and build and sustain trusted medical neighborhoods through a defined communication protocol. It specifies key areas of a mutual care management agreement like transitions of care, access, collaborative care management and patient communication. If you are interested in holding a meeting in your care community to learn more or test the care compact then contact Chet Seward.

There are currently two versions of the compact: 

1) 101 basic version that serves as a framework for care coordination agreements between physicians; and

2) expanded version that incorporates definitions, care coordination agreements and key clinical information to be exchanged during shared patient care between physicians. 

Work on these compacts continues to evolve. Please review the compact and send us your feedback.

Interested in implementing the compact in your practice? We can help. Contact Chet in the CMS offices.

PCMH/medical neighborhood physician poll results

A statewide survey of 10,725 Colorado physicians was conducted in the Fall of 2009 to assess perceptions and barriers to becoming, or working with, a medical home. Poll result highlights include: 1) 72% of primary care physicians (PCPs) and 76% of specialists indicated a high level of support for medical homes and care delivery models that promote coordinated. 2) Patient-centered care and the most compelling reasons to become, or link to, a medical home was driven by interests in improving health outcomes, patient satisfaction and care coordination. 3) Many barriers currently exist that perturb the development of medical home communities.

SOC/PCMH priorities

• Simplify the message and create a coordinated approach.
• Provide education and resources to physician practices to support actionable steps around the medical home model.
• Focus on improving physician communication and understanding between primary care and specialty care physicians.
• Support policy changes that advance medical home and medical neighborhood models like payment reform and health information exchange/HIT.