Photo from Spanish Peaks www.sprhc.org/clinic.html

Spanish Peaks Regional Health Center in Walsenburg has something to crow about. On November 1st the facility learned it is the first Critical Access Hospital in Colorado to obtain National Committee for Quality Assurance (NCQA) patient-centered medical home certification for its outpatient primary care clinic.

Bill Bolt, CIO/Practice Administrator, Spanish Peaks Regional Health Center, said the process of gaining the certification is allowing the facility to deliver better care. “Perhaps the most important new processes we have now are the ones that focus on patients being full partners in working to improve their own health,” Bolt said. He said NCQA-required data measurement processes will also be critical to their continued success.

A look at the websites below will demonstrate how much energy is being funneled toward the medical home concept in Colorado. The sites also give you a sense of the importance healthcare leaders put on the successful implementation of medical home systems. But first, what is a medical home? And what does it look like in rural Colorado?

It’s you (or could be you). Here’s why: you know your patients and their families; you don’t deliver duplicative care because you know what care you’ve delivered. Your patients know to come to you for care coordination (okay, often in your rural community there is nowhere else for them to go); you keep track of their tests and immunizations so you can alert them when one or both are recommended; you are their one-stop medical shop.

NCQA certification provides an opportunity to adopt evidence-based practices and track and measure clinical outcomes. Hopefully, as the adoption of this model becomes more widespread, it will lead to payment reform that is focused on reimbursement based on patient outcomes instead of fee for service.

While none of this sounds especially over-the-top in terms of innovation, it is different in urban areas. In larger communities it is not unusual for patients to receive care from a myriad of facilities, none of which communicate especially well (or at all) with each other. Diagnoses are missed. Expensive tests are performed multiple times. Patients are left confused at what to do or who to see and miserable due to the many hours spent waiting for appointments and for the drain the appointments put on their bank account. Payers aren’t happy; the whole merry-go-round costs a fortune. Employers, watching their productivity tank, are wondering why all their workers seem to need endless amounts of care for what are often very treatable maladies.

Medical homes first appeared on the scene as a concept back in the late 1960s, with a pediatric focus. The idea emphasized the importance of centralized medical records for children with special healthcare needs. Since that time the concept has migrated to influence the delivery of care to patients of all ages, and includes incorporation of evidence-based guidelines, referral coordination, cross-cultural sensitivity, and a sophisticated health information technology platform. Medical homes provide accessible, family-centered, continuous care that recognizes the patient as a whole person.

CRHC is honored to be working with rural health facilities across Colorado in pursuing medical home status through our Rural Health Clinic technical assistance programs. We are currently in the second year of a three-year, $1.5 million grant from the Colorado Health Foundation. In close partnership with Health TeamWorks, the work involves 22 clinics in southeastern Colorado. CRHC’s Matt Guy, based in Pueblo, is our point person for this effort. The ultimate goal is for these clinics to become NCQA certified as patient-centered medical homes.

We are working in partnership with the Colorado Community Health Network and ClinicNET on an initiative funded by the Commonwealth Fund, focusing on 13 Colorado safety net clinics pursuing medical home status.

For more information about other Colorado medical home initiatives you can visit the following websites, or contact Matt Guy at mg@coruralhealth.org so he can help you understand more about what is happening with medical homes in Colorado and nationally.

• Health TeamWorks
• The Colorado Medical Home Initiative, created by Senate Bill 07-130
• Colorado Academy of Family Physicians
• Colorado Beacon Consortium