How One FQHC Developed Its Own PCMH Model

When operating in a mostly fee-for-service environment, full implementation of a patient-centered medical home (PCMH) model can be limited by financial sustainability issues. One federally qualified health center (FQHC) decided to take action and created its own PCHM model.

But first, what exactly is the PCMH model? The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not just as a place, but as a model for organizing primary care that provides the essential functions of primary healthcare. The PCMH model includes five key functions and attributes: comprehensive care, patient-centeredness, coordinated care, accessible services, and a focus on quality and safety.

Healthcare Innovation recently interviewed Talya Hellman, Director of Strategic Initiatives at Access Community Health Network (ACCESS), an FQHC that provides primary and behavioral healthcare to nearly 150,000 low-income residents in the Chicago metropolitan area through 34 sites. As value-based care continues to grow, ACCESS recognized an opportunity to develop its own PCMH model focused on improving health equity, clinical outcomes, and patient satisfaction, while reducing costs and increasing staff work satisfaction.

Could you provide some background?

ACCESS has been around since 1991. Our population is both urban and suburban. Nearly 90 percent are at or below 200 percent of the Federal Poverty Level. The majority are either black, African American, or Hispanic. It tends to be more of a complicated population than standard primary care.

We have been a PCMH model for about 10 years or so. We’ve had the accreditation. In parallel with that, we developed a model, but it was more of a philosophy than a model in terms of patient-centeredness. We adopted the joint principles of PCMH in terms of thinking about care coordination: coordinated care with the patient at the center.

We have behavioral health consultants throughout our organization, as well as psychiatry services embedded. The idea, though, is that we're coordinating care, whether it's for medical, behavioral health, or social needs related to health, such as food insecurity, transportation, housing, and connecting people to resources.

We are going through a transformation process, as are many organizations right now, for a number of reasons. One, there's just an opportunity to do better in terms of quality of care. Secondly, there's an opportunity to sort of leverage an even broader care team so that everyone is operating at the top of their license right now. Our providers do a lot of the work, and other care team members could probably be doing it instead, so that providers have more time to spend with more complicated patients.

There’s just a lot of opportunity to provide more value. And with that, there's also a shift in the reimbursement environment, which is how health centers are being paid, but also to value-based care contracts. Taking on risk shared savings, and obviously, to be successful in that, you need to improve in quality.

About two years ago, we decided we needed to change our model. Where were some foundational things we needed to do that weren't even around transformation, but more around standardization, because we have 34 sites that were grown, but not necessarily standardized very well. The CEO felt that we needed to operate more effectively, and challenged a few of us to develop a new framework or model that could be executed as a playbook.

There are a lot of frameworks out there now, in the literature, and NACHC (National Association of Community Health Centers) has also done a really great job… in terms of thinking about key foundational activities you need to do for value. We were using a risk stratification tool, but it wasn't great, it wasn't automated, and it was self-report. It's very difficult to manage populations if you're not empowering them accurately.

We looked at all the other models out there and took the best of what we liked; what made sense for us as an organization and our population, what our patients care about, and what our staff care about. We created a new framework with new pillars, a lot of which overlap with PCMH. But it was tailored to us, and now we're in the implementation phase.

How was the new model formulated; who sat at the table?

There were three of us who were kind of like the stewards. We came at it from three different vantage points. My background is strategic planning and service line building. I was there to help organize and collect all the thoughts and synthesize all the information. Then we had our VP of Population Health Strategy and Quality. She has a really extensive background in value-based care contracting. The third one of us is our VP of Operations for Patient Access and Experience, she’s a provider as well.

The three of us would then take the information to different audiences. We formed what we call our Model of Care Task Force, which has a large membership. It's about 15 to 20 people, and we meet monthly. It includes disciplines from the whole organization. Every region has a Regional Operations Manager and a Regional Medical Director. It had both the providers and the operations people, but then it also had our Epic team. We had our care coordination and case management teams on there. We had our VP of Revenue Cycle there and our communications staff.

It’s really a multi-disciplinary team, and they're just like a really important sounding board. We worked with them to define our services.

What are some examples of what has been done?

Before we had a risk stratification tool, we used the SF-12, and we basically screened every patient using that. We now have, running in the background, an automated scorecard that we've developed and validated using Epic. One that's running in the background, and then use that in different applications to drive certain things. For example, it's now being used to drive outreach in a more targeted way to different populations using automated campaigns and manual outreach. It's also being used to determine whether certain patients need longer appointment times. The provider can see on their dashboard what the patient's risk is and decide if they need more support. We're already seeing a lot of uptake in referrals. We're hoping that next year it will allow us to look at our data better and understand what's going on from a population standpoint.

The other piece we've done is building a measurement system, a performance system, of how we're performing on our model of care. And we decided that the quintuple aim is basically our North Star in terms of outcomes that we want to see. We've been very heavy in focusing on clinical quality, but to us, it was really important as an organization that we need to be looking at everything in one place. So we need to be looking at not just clinical quality, but also utilization, patient satisfaction, staff satisfaction, cost. We created a scorecard with the five domains. Equity is the fifth measure.

What were some of the challenges you experienced while building this new model?

I feel like we're still in the early days of rolling the framework out and even defining what we mean by model of care for the organization. I think it took several rounds for us to figure out how to discuss this in a way that's meaningful to folks and doesn't feel abstract.

We prioritized the projects that we needed to implement first. Some of them were foundational; that's why we have to do this now, because otherwise we can't do all of these other great things. But some of them are picked because these things are going to generate revenue right now, and we need it right now. Just juggling the current financial climate as well, in terms of having to prioritize projects and being okay with some things taking a bit longer, because we were having to prioritize other things that could generate revenue.

How do you do care management on a shoestring budget?

At ACCESS, we don't have care management for everybody. We have a delegated contract with one payer, and then we have care coordination. We do care coordination, the fee-for-service model for Medicare patients with chronic care management. There is no way that we will ever have enough care coordinators or care managers to provide every patient with services. However, like right now, we're not even necessarily directing those high-risk folks to resources where they can get care management. So for example, all of the plans provide care management but we haven't had the sort of correct configuration to even direct them into care management. We just need to figure out the right systems to be able to direct folks into the right resources, because they're never going to be all in one place, and we're never going to be able to do all of it, but at least we need to have the resources to get people to the right care.

Could you speak to some of the advances that you're seeing?

I think back to the risk stratification piece, which is where we started. Where we started on the implementation side, we saw, within two months, 90 patients referred into care court, into our chronic care management program.

I think that other things we've learned are really great features of our Epic technology. As we've been building out this scorecard, we've just been able to pull everything into one dashboard.

Do you feel the model has changed?

I don't think we're quite there yet. I think that's 2026. Right now, we're sort of on the cusp of thinking through the care team piece. We've got plans in place, but we're still finalizing those, and I think those will come into play in 2026. We’re really still at the beginning of this journey, and a lot of it has been sort of discovery in terms of what our baseline is, what our current situation is.