Samaritan Family Health Network’s eight primary care centers received recognition from the National Committee for Quality Assurance (NCQA) as a NYS Patient-Centered Medical Home (PCMH) practice at the 2017 standard, the most recent standard available.
This recognition is given to practices in New York State that meet a rigorous set of qualifications within six concept areas:
- Team-Based Care and Practice Organization
- Knowing and Managing Your Patients
- Patient-Centered Access and Continuity
- Care Management and Support
- Care Coordination and Care Transitions
- Performance Measurement and Quality Improvement
The principles of patient-centered care align with the momentum toward value-based payment, and ensuring that patients get the right care at the right time, at the right place. Samaritan’s success has been profiled in a case study encouraging other NYS health centers to become PCMH recognized.
The coordinated effort on Samaritan’s end has led to patient care success; specifically this work has led to decreased Emergency Department visits and lower A1C levels in diabetic patients. In addition, the following improvements have been made:
- Better communication: Communication improved across the organization – between clinicians, and between patients and the office. This led to better provider and patient engagement.
- Stronger care management: The care management program allows patients to spend more time with a nurse discussing more complicated health concerns. This helps patients better manage chronic conditions.
- Patient-centered access: Clinical availability shifted from provider schedules to patient needs. This means patients with urgent care needs can be seen sooner.
- Behavioral health integration: Process improvements increased behavioral health screenings by the tens of thousands per year. Integration of a Licensed Clinical Social Worker (LCSW) into the practice meant primary care physicians could bring in a behavioral health professional immediately if they suspected possible life-threatening issues.
- Population health management: Process and workflow changes, combined with stronger Health IT infrastructure, led to better overall population health management.
“Changing an entire primary care model with eight centers is a tremendous feat for any healthcare organization. Our team of 28 providers and staff took on the challenge. They are willing and ready to help improve patient outcomes and they have succeeded,” states Mike Gonzales, MD, MHSA, Samaritan Family Health Network Administrator.
Samaritan Medical Center received its first PCMH recognition in 2011. This is the second time receiving the NYS PCMH 2017 recognition, the NYS-specific program that is built upon the NCQA PCMH model and which was rolled out in April 2018. All eight of Samaritan’s primary care sites are recognized:
- Adams Family Health Center
- Cape Vincent Family Health Center
- Clayton Family Health Center
- S.M.A.R.T Clinic (Graduate Medical Education) (Watertown)
- Lacona Family Health Center
- LeRay Family Health Center
- Watertown Family Health Center
- Sackets Harbor Family Health Center
Fort Drum Regional Health Planning Organization (FDRHPO) was instrumental in helping Samaritan gain this recognition. They have assisted primary care practices in Jefferson, Lewis, and St. Lawrence Counties achieve PCMH recognition. FDRHPO’s team of Practice Transformation specialists work closely with partnering practices to navigate the recognition process, from policy formation and adoption, to workflow transformation, and formal submission for recognition. To learn more about NYS PCMH please visit: www.ncqa.org/nyspcmh.