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New Care Models

Accountable Care Organizations

To encourage primary care doctors, specialists, hospitals and other healthcare providers to coordinate their care, a final regulation has been issued for Accountable Care Organizations (ACOs). Created under the Affordable Care Act, ACOs are one of several options for providers seeking to better coordinate care for patients. ACOs are intended to help providers deliver high quality care and use healthcare dollars more wisely.  ACOs can achieve performance bonuses for meeting 33  quality measures. Participating providers also no longer are required to use electronic health records. Providers also can sign up without agreeing to pay Medicare if they do not achieve savings. However, those who agree to assume the risk of cost overruns in turn would be eligible for greater rewards. Community health centers and rural health clinics are eligible to lead ACOs, and providers will be able to learn up front which patients are eligible to receive care in their ACO.
For more information and fact sheets, visit and the CMS website.   

Patient-Centered Medical Home

This is a new model of organizing a patient’s care across a continuum of care providers. In addition to being a “place”, such as a practice or community health center, it is also a concept that typically encompasses several functions or attributes (e.g. patient-centered, coordinated care), and payment may be available for some coordination. Health information technology, or electronic health records (EHRs), are an essential component of medical home coordinated care. A number of demonstration projects are underway or have been completed, including those sponsored by the HHS/Centers for Medicare & Medicaid Services (CMS), and the National Quality Forum has processes and standards for certifying Medical Homes. Several definitions and resources are included below.

National Quality Forum Patient Center Medical Home 2011

NCQA’s Patient-Centered Medical Home (PCMH) 2011 is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams, and coordinating and tracking care over time. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

The HHS/Agency for Health Quality Research

AHQR defines the primary care medical home (PCMH) as “a promising model transforming the organization and delivery of primary care.” The AHRQ website provides policymakers and researchers with access to evidence-based resources about the medical home and its potential to transform primary care and improve the quality, safety, efficiency, and effectiveness of U.S. health care. Vist the AHQR web site for more information.

There are several new opportunities, among them:

  • The CMS Center for Medicare and Medicaid Innovation (CMMI)

CMS has implemented the Medicare Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP) and Federally Qualified Health Center Advanced Primary Care Demonstration (FQHC APCP). They are also developing other demonstration projects that will test and evaluate advanced primary care models of care delivery and payment.

  • Federal PCHM Collaborative

The Collaborative created a Catalogue of Federal PCMH Activities of PCMH-related work. The Catalogue provides information about ways the agencies are working together to promote a strong primary care delivery system, which includes supporting promising models of primary care transformation like the PCMH and can be accessed by clicking on the links below:

In March 2007, the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and American Osteopathic Association (AOA), representing approximately 333,000 physicians, developed and published joint principles to describe the characteristics of the PCMH.

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