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 medical home? How about 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. Click here to learn more. A medical neighborhood fosters shared accountability by linking specialty care and primary care physicians together to provide integrated, patient-centered care.

SOC/PCMH Initiative Priorities
Priorities for the Initiative include:

· 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.

SOC/PCMH Initiative Fact Sheet

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 Karen Frederick-Gallegos at Karen_frederick-gallegos@cms.org or 720-858-6323 to learn more.

Primary care-specialty care compact

The SOC/PCMH initiative is developing 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.

There are currently two draft 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 Karen in the CMS offices.

What's the literature say?
Click here to obtain a comprehensive bibliography and related articles.

Colorado Medicine Articles:

Vision for the Future; Sara Burnett, Colorado Medicine, November/December, 2009

Physician Perceptions on Care Coordination; Karen Leamer, M.D. and M. Eugene Sherman, M.D., Colorado Medicine, January/February, 2010

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.

To learn more about the results of the SOC/PCMH Survey, see a two page summary and powerpoint presentation below:

- Kupersmit Research SOC/PCMH Poll Highlights

- Kupersmit Research SOC/PCMH Poll Result Presentation

Partners

The Systems of Care/Patient Centered Medical Home initiative is a collaboration between the Colorado Medical Society, Colorado Academy of Family Physicians, Colorado Society of Osteopathic Medicine, Colorado Chapter of the American Academy of Pediatricians, Colorado Chapter of the American College of Physicians and Health Team Works.

Funded by:

The SOC/PCMH Initiative is generously funded by the Colorado Health Foundation. The Colorado Health Foundation works to make Colorado the healthiest state in the nation by investing in grants and initiatives to health-related nonprofits that focus on increasing the number of Coloradans with health insurance; ensuring they have access to quality, coordinated care; and encouraging healthy living.