When a practice is in the “succeed” phase of Patient-Centered Medical Home recognition, it is important they do just that – succeed in the activities they have diligently worked on during the transformation phase. All too often, after the initial recognition is achieved, practices slide back to their old ways of doing things and the efforts they put into achieving recognition are not sustained.

Our PCMH Sustainability Service is conducted through a series of touch points of communication and work throughout the year. Each consists of about eight hours of advising and is done remotely. We review reporting and quality improvement efforts, and we perform miniature audits geared to ensure that your practice is maintaining the workflows, roles, responsibilities and processes established during the transformation phase.

As with all of our engagements, our Sustainability Service is fully customizable. Your practice can add to the base service to meet your unique needs. For example, medical groups with multiple locations may want more hours per quarter to work through strategies, reporting and individual practice level support, or your practice may be interested in annual in-person training for staff.

Examples of additional focus areas for services include:

  • Q-PASS Navigation
    We provide assistance with the administrative activities associated with Q-PASS.
  • Practice Retreat Facilitation
    We offer customizable education provided on PCMH foundational elements and maturing your medical home to meet patients where they are.
  • Quality Improvement/Performance Improvement
    Our advisors create QI strategies, provide data analysis assistance, establish Plan-Do-Study-Act cycles and engage staff in the QI process.
  • Value-based Payment
    We help ensure base requirements are continued and align your PCMH measures with your risk-sharing arrangements and other initiatives.
  • Care Coordination
    We help you achieve advanced communication and improved relationships throughout the healthcare continuum with specialists, hospitals and community based organizations, improving your patient’s healthcare journey beyond your four walls.
  • Social Determinants of Health
    We help your practice identify the disparities facing your patient panel, provide education on the SDoH impact regarding overall health and offer tools to support the needs of your panel.

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