All Intermountain primary care clinics earn Patient-Centered Medical Home Recognition

“NCQA Patient-Centered Medical Home Recognition raises the bar in defining high-quality care by emphasizing access, health information technology, and coordinated care focused on patients,” says NCQA President Margaret O’Kane. “Recognition shows that Intermountain’s clinics have the tools, systems, and resources to provide their patients with the right care, at the right time.”

Caregivers and providers from all 81 clinics have been working hard since late 2017 to meet the requirements to earn the Patient-Centered Medical Home Recognition. The work was led by Shauri Kaugie, RN, Camie Carr, RN, and Nicole Boudreaux. To meet the criteria, multiple system standard processes had to be implemented and the clinics had to demonstrate they were following the processes.

“The thing I really love about the NCQA Patient-Centered Medical Home model is the focus on what patients want and need from primary care,” Shauri says. “This is personal for me because my family has experienced the consequences of when primary care doesn’t meet the patients’ needs. This PCMH model focuses on health, closing care gaps, helping those with chronic complex conditions, working as a team, providing access when and how patients want it, providing coordinated high-quality care, and always striving to improve. This is the care we need to be providing with goal to continue to focus on the patients we’re privileged to serve.”

Some initiatives Shauri says Intermountain implemented to earn the recognition:

• Launching a centralized after-hour phone line, Health Answers, which is staffed with experienced registered nurses. This has decreased the call burden for primary care providers and improved patient access. There’s also a report documented in the electronic medical record that shows how long it took for the patient to receive a call back and all clinical advice provided.
• Administering a regular comprehensive health assessment to all patients that includes assessment of social functioning, social support, and social determinants of health. “This has helped us start the important work of addressing all aspects of health and start to address health disparities and inequities that are present in healthcare,” Shauri says. 
• Asking patients when they prefer to be seen and by what method — including phone calls and video visits. “This information will help us be responsive to our communities’ needs,” she says. 
• Ensuring referrals are getting to where they need to go and specialist reports are being returned back to primary care provider. “The intent is to ensure patients get the secondary care they need when they need it, reduce duplication of services, and provide coordinated care,” she says.

“The NCQA guidelines have helped us better communicate as a care team” says Conrad Jacobsen, practice director for the Central Orem Clinic. “For example, in addition to our daily huddles with the providers, we’ve implemented a weekly caregiver huddle that helps us discuss NCQA-related topics on an as-needed basis. This helps us all be on the same page when it comes to meeting our Personalized Primary Care goal metrics.”

Jen Wilden, practice manager for Southridge Clinic Pediatrics, shares this example of how the PCMH guidelines helped her team help a patient in need: “Our care guide cold-called a patient. After talking with the patient’s mom, the care guide noted the patient had signs and symptoms of depression. The care guide helped get her in to see her doctor within two days. The patient’s mom had no idea we had so many resources to help with depression. Bravo to Dr. Sadie West, mental health integration, and the care management team.”

The changes Intermountain has implemented to receive PCMH Recognition mean these benefits for patients:

• Lower cost of care
• Easier to get appointments
• Access to clinical advice 24/7 through a centralized phone number
• A referral tracking system helps you connect to specialty-care needs
• A consistent experience across the system because all clinics are working on same quality metrics
• Mental health integration within primary care

Benefits of the PCMH recognition for providers:

• Better work-life balance because they’re fielding fewer after-hours calls
• Large amount of Maintenance of Certification credit for work related to NCQA PCMH Recognition
• Improved patient outcomes and satisfaction

Benefits for Intermountain:

• The clinics meet eligibility requirements for the SelectHealth Medical Home Pay for Performance Program, which will bring approximately $2.2 million to the Intermountain Medical Group annually.
• The recognition helps SelectHealth sell more plans on the open market and entice more members to participate in health plans.
• Increased preventive care and screenings for all relevant patients
• Timely patient follow up that results in increased primary care utilization
• Fewer open timeslots because of optimized scheduling.
• Fewer appointment no-shows because of improved contact and relationships with primary care team and patients.
• More efficient use of the care team.

Health systems with many primary care providers who participate in NCQA PCMH had higher quality outcomes and lower costs. Organizations with PCMH Recognition have a:

• 1.5 percent reduction in specialty care visits
• 1.4 percent increase in breast cancer screenings
• 4.2 percent decrease in total healthcare spending for higher morbidity patients
• 2.25 percent reduction in total healthcare spending

Full list of Intermountain clinics that received the Patient-Centered Medical Home Recognition:

• Alta View Clinic Pediatrics
• Alta View Internal Medicine
• American Fork Internal Medicine
• Avenues Internal Medicine
• Bear River Clinic
• Bountiful Family Medicine
• Bountiful Internal Medicine
• Bountiful Pediatrics
• Budge Clinic Family Medicine
• Budge Clinic Internal Medicine
• Budge Clinic Pediatrics
• Canyon View Clinic
• Cedar City Clinic
• Central Orem Clinic
• Cottonwood Family Medicine
• Cottonwood Internal Medicine
• Draper Clinic
• Ephraim Clinic
• Fillmore Clinic
• Heber Valley Clinic Family Medicine
• Highland Clinic
• Hillcrest Pediatrics
• Holladay Clinic Internal Medicine
• Holladay Pediatrics
• Holladay Pediatrics North
• Hurricane Valley Clinic
• Hurricane Valley Clinic Peds
• Intermountain Pediatrics - American Fork
• Intermountain Pediatrics - Orem
• Intermountain Senior Clinic
• Kaysville Creekside
• Kearns Clinic Pediatrics
• Kearns Clinic
• Layton Clinic Family Medicine
• Layton Parkway Northern Utah Pediatrics
• Lehi Clinic Family Medicine
• Logan Clinic Family Medicine
• Manti Clinic
• McKay Dee Internal Medicine Clinic
• McKay Dee Porter Clinic (Residency Clinic)
• Memorial Clinic Internal and Family Medicine
• Memorial Pediatrics
• Mountain Family Health
• Mt. Pleasant Clinic
• North Cache Valley Clinic
• North Canyon Clinic
• North Ogden Clinic
• North Orem Clinic
• North Sevier Clinic
• Northern Utah Pediatrics at McKay-Dee
• Payson Clinic
• Redrock Pediatrics
• River Road Family Medicine
• River Road Internal Medicine
• Rose Canyon Clinic
• Round Valley Clinic
• Roy Clinic
• Salt Lake Clinic Bryner Pediatrics
• Salt Lake Clinic Internal and Family Medicine
• Saratoga Springs Clinic
• Sevier Valley Clinic
• South Cache Valley Clinic
• South Jordan Clinic
• South Ogden Clinic
• South Sandy Clinic
• South Sevier Clinic
• Southridge Clinic Pediatrics
• Southridge Medical Specialties
• Springville Clinic
• Sunset Clinic
• Sunset Clinic Pediatrics
• Syracuse Clinic
• Taylorsville Clinic Family Medicine
• Utah Valley Internal Medicine
• Utah Valley Senior Clinic
• Valley View Family Medicine Clinic
• West Jordan Clinic
• West Valley Clinic Family Medicine
• White Sage Family Medicine