Pennsylvania’s Patient-Centered Medical Home Learning Collaborative Enters Exciting New Chapter
Type: News
Focus Area: Workforce Development
An April 17, 2019 PCMH session.
Patient-Centered Medical Homes (PCMH) embody a model of health care that seeks to provide better quality, improve self-management by participants of their own care, and reduce avoidable costs over time. These values align closely with the Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative, and a statewide learning collaborative designed to support PCMH practices in Pennsylvania is transforming in 2025 to further advance these practices at improving care for their patients.
Between 2008 to 2016, PRHI embarked on a journey of investing in primary care to keep people out of hospitals in response to findings from PHC4 data that showed chronic conditions, including behavioral health, as the top drivers of hospital readmissions. During this period, PRHI implemented behavioral health screenings and treatment in primary care offices, established hospital-based primary care resource centers with care managers and pharmacists, trained primary care teams how to meaningfully use their new electronic health record systems to improve patient care and population health outcomes, advocated for policies to support Community Health Workers (CHWs), helped primary care offices meet new PCMH requirements, which included performance incentives from payers. PRHI’s shift to “putting the prime in primary care” was initially catalyzed by funding from foundations and then scaled with larger federal grants from the Agency for Health Research & Quality, Center for Medicare and Medicaid Innovation, and the Office of the National Coordinator for Health Information Technology.
A July 2024 PCMH session discussion about the program’s forward movement.
On the heels of this track record, the Pennsylvania Department of Human Services established the “HealthChoices PCMH Program” as a new value-based payment model in 2017. In this model, the Physical HealthChoices Managed Care Organizations (MCOs) make agreements with high-volume providers in their network who meet initial requirements, collect quality-related data from the PCMHs, reward PCMHs with quality-based enhanced payments, and develop a learning network that includes PCMHs and other MCOs.
The contracted PCMH providers are also expected to screen patients for Social Determinants of Health (SDOH), deploy Community-Based Care Management teams including professions such as CHWs, involve family members or patient advocates on their team to advise on improvements, measure patient satisfaction, see patients following discharge from the hospitals, provide or refer to Tobacco Cessation Counseling services, and participate in a PCMH learning network.
“The Department of Human Services (DHS) was committed to investing in evidence-based enhancement of primary care through the PCMH program, which was developed with input from the PCMH Advisory Council and other stakeholders. The PCMH program was implemented through the HealthChoices MCO contracts, and the PRHI has provided technical support for the Learning Network requirements since its inception,” said David Kelley, MD, MPA, Chief Medical Officer, Office of Medical Assistance Programs, DHS.
Ever since, PRHI has facilitated quarterly learning sessions for participating PCMHs in western and northeastern regions of Pennsylvania, and the Health Federation has facilitated quarterly sessions for the providers in the southeastern and Lehigh/Capital regions. The learning sessions include content expert speakers and peer-to-peer learning strategies to spread best practices for how to incorporate the HealthChoices PCMH Program’s requirements into the PCMHs’ daily workflows and team roles. In 2024, PRHI also rolled out an affiliated learning network for PCMH providers to improve care coordination for children with complex medical needs who are receiving pediatric shift care services.
“This was the right policy development and time for PRHI to package, scale and sustain our primary care experience across the Commonwealth,” says Robert Ferguson, MPH, PRHI Chief Policy Officer. Knowing that PRHI could convene the right statewide partners and effectively organize the PCMH Learning Network, PRHI submitted a proposal to the Physical Health MCOs to develop and facilitate the learning network for the HealthChoices PCMH Program. PRHI partnered with the Health Federation of Philadelphia, which also had a unique track record in integrating behavioral health in primary care and providing training and technical assistance to community health centers.“The Health Federation was excited to become a partner with PRHI and the HealthChoices MCOs in supporting the PCMH Learning Network. We have been able to leverage our strong relationships with FQHCs across the state and our team’s population health expertise in areas like quality improvement and social drivers of health for a broad audience of primary care providers and MCOs,” said Susanne Cohen, senior director of population health, Health Federation of Philadelphia. “Our team greatly enjoys working with the diverse community of highly committed primary care providers through this initiative.”
Leading into 2025, PRHI and the Health Federation worked with the MCOs to redesign the HealthChoices PCMH Learning around five focus areas called “sprints” and held a statewide kickoff session on January 22 with all the providers and MCOs. Each PCMH provider selected to participate in one of the following sprints: Well-Child and Well-Care Visits, including Lead and Development Screenings; SDOH Interventions; Post-Hospital Follow-up and Readmission Prevention; Pediatric Nursing Care; Blood Pressure Control and Asthma Medical Ratio. The sprint topics were informed by MCOs, PCMHs, and data from pay-for-performance measures, creating statewide alignment around a set of prioritized focus areas for 2025. Throughout the year, PRHI and the Health Federation will be organizing learning sessions for each statewide sprint. The PCMHs in their learning and implementation sprint cohorts will receive tactical, how-to information from content experts and peers, track the key interventions they implement during sprints, and receive recognition for their quality improvement accomplishments during statewide sessions in June and November.