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Congratulations to UVA Orange Pediatrics for becoming recognized as a Patient-Centered Medical Home (PCMH). This is the first time the Department of Pediatrics has earned the designation, and they are only the second department in the Health System with an active PCMH recognition.

What is PCMH?
The PCMH model represents patient-centered, all-encompassing care that is continuously improving.

“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,” said NCQA President Margaret E. O’Kane.

How did UVA Orange Pediatrics do it?
“To achieve recognition, the team had to commit to continuous quality-improvement processes and to a patient-centered approach to care over the long term,” said Rachel Moon, MD, Professor of Pediatrics and Division Head of General Pediatrics. “This involved developing multiple clinical protocols and policies and conducting more than 20 quality-improvement projects simultaneously. Every day, the Orange Pediatrics staff are working on improving processes to make patient care better and more efficient.”

Betsy Schinstock, MD, Assistant Professor of Pediatrics and Medical Director of UVA Orange Pediatrics, has led the Orange clinic in their work toward the PCMH recognition. She said the certification requirements helped identify gaps in care and where to focus their efforts.

For example, the clinic wanted to better screen for social determinants of health, but they were lacking resources to do so effectively. Through the PCMH process, they were able to identify the proportion of patients who needed additional case-management services. The data that they collected demonstrated the need, and they received approval to hire a social worker and a patient navigator. Team members in those new roles identify which patients need additional services and ensure follow through with that care.

How has the clinic changed?
“We definitely have fewer patients falling through the cracks,” Schinstock said. “We’ve streamlined and made a lot of our practices more consistent. We are screening more. We are explicitly asking what our patients’ needs are.”

All new mothers are screened for postpartum depression. Developmental delays in toddlers are identified earlier and more easily. The team tracks patients with mental-health concerns and intervenes before they reach a state of crisis.

Schinstock attributes the success of Orange Pediatrics to the hard work of the entire team and the support they received from Family Medicine. “Thank you to everyone who helped us with this great achievement,” she said.

Family Medicine
Family Medicine, the first department to receive a Level 3 PCMH recognition, has retained the designation since 2015.

“The recognition is the result of collaborative problem solving and the engagement of all team members, including clinic leaders, providers, nurses, pharmacists, social workers, care coordinators, and patients,” said Becky Compton, DNP, Associate Medical Director. “PCMH guidelines provide a framework to ensure our care process remains patient-centered.”

What’s next?
Family Medicine and Pediatrics plan to seek renewal in 2020. Pediatrics hopes to expand the number of clinics with the PCMH recognition over time.

Family Medicine and Pediatrics are available to coach other areas interested in earning the PCMH recognition. Contact Becky Compton or Betsy Schinstock with your questions.

RELATED READING: Hard Work Pays Off: Family Medicine Retains Its Patient-Centered Medical Home Status