The contents of this Implementation Guide are largely based on CareOregon’s 5-year experience with the Primary Care Renewal (PCR) Collaborative. That work in turn benefited greatly from multiple site visits to other organizations implementing medical homes, primarily from the Southcentral Foundation in Anchorage, Alaska but also from others such as Group Health of Puget Sound, and from general participation in the national medical home dialogue.
PCR began in 2007 when CareOregon and 5 of its major primary care providers set out on a collaborative journey to implement the “robust medical home” model of care they had seen in a visit to the Southcentral Foundation (SCF). This model was structured around patient-centered and population focused provider teams. The teams were collocated to optimize close working relationships and had been told their job “was not visits but getting the best health outcomes for the panel of patients who had chosen them for care” (see Module 1 for more on SCF).

Each team had access to panel reports that indicated individual patient care needs which allowed them to reach out to address gaps in care rather than waiting for the patient to come in for a visit. Southcentral was continuously refining the model to ensure the best role for each team member so that each was working at the top of his or her license and capability. The Southcentral leadership had already brought sophisticated improvement methods to the organization, had established their own Development Center to train their workforce, and were continuously looking for new methods to help them do their work better.

The pioneers in the PCR journey were Central City Concern, Legacy Internal Medicine, Multnomah County Health Department, OHSU Richmond Family Medicine, and the Virginia Garcia Memorial Health Centers.

Starting with a single pilot team in a clinic, each organization used rapid tests of change to develop the workflows that made the new model work. Training in process improvement (PI) methods was provided to the teams and designated PI coaches identified by each organization. The pilot clinic teams met every 6 weeks to share what they had learned with each other to further accelerate learning.

After 8 months, the groups began to spread their new model to the other providers in the pilot team clinic; soon thereafter, organizations with multiple clinics began clinic-to-clinic spread. After 4 years, 18 clinics with close to 80 teams had implemented the PCR model.

In 2009, a new quality bonus payment model was co designed by leaders from the clinic organizations and CareOregon that rewarded improvement being demonstrated in the key clinical metrics. Measures of patient experience showed a high degree of patient-centered care.

By 2010, decreases in hospitalizations and ED visits were being seen. In 2010, a major new initiative to embed evidence-based care management for depression and diabetes was begun in order to expand the clinics ability to provide self-management support to their patients.

None of the organizations would say they are “done” implementing this patient- and population-centered care model. But all would agree that a lot has been learned that should help others progress more quickly on this journey.