PCMH PRIME: A New Integrated PCMH Approach

February 18, 2016 · Matt Brock

There is big news from the towering NCQA offices in the Nation’s Capital. It is a new opportunity–known as PCMH PRIME–for practices in Massachusetts. Still, this news is not just of interest in The Bay State. It has implications across the country.

Massachusetts’ Health Policy Commission (HPC), in collaboration with NCQA, developed the PCMH PRIME certification program that endorses practices passing NCQA’s rigorous guidelines for patient-centered care while also maintaining additional behavioral healthcare services for their population.

“NCQA strives to increase patient access for needed behavioral health services, and including behavioral-specific requirements in our PCMH 2014 recognition program was the first step,” said NCQA president, Margaret E. O’Kane. “We are proud to work with HPC on a new certification program to further integrate behavioral health into the primary care setting.”

The Basics on PCMH PRIME

As many folks already know, NCQA PCMH Recognition requires practices to meet rigorous, evidence-based standards. But now, in Massachusetts, practices that go through the recognition process can earn PCMH PRIME certification if they meet at least 7 out of 13 behavioral health criteria, including:

• Co-locating or entering into formal agreements with behavioral healthcare providers.
• Integrating behavioral healthcare providers into the practice site.
• Performing comprehensive health assessments that include screening for behavioral health conditions like depression, post-partum depression, anxiety, developmental delays and substance use disorder.
• Having a system for identifying high-risk patients for targeted care management.
• Tracking and following up on referrals to specialists, including behavioral healthcare providers.
• Medication-assisted treatment (MAT) for patients with addiction.

The PCMH PRIME certification is voluntary. The Commonwealth’s Health Policy Commission does offer technical assistance to practices that undergo certification. The details are here and here.

Now, Other States.

We asked NCQA’s Director of State Affairs about the implications this program will have on generating similar programs in other states.

“It’s the first state using NCQA’s PCMH as a framework to feature behavioral health,” Kristine Toppe told us. “We believe many more states could follow given the growing adoption of the medical home model and the need for greater attention to behavioral health.”

From Toppe’s standpoint, Massachusetts is paving a path for others. “Using the NCQA PCMH gives the program a strong and trusted foundation that doctors and insurers understand while allowing the state to focus on a key health issue within the state,” she explained. “Using a standardized and tested model for defining a medical home means you can compare practices and objectively assess the benefit of the program.”

Toppe expects other states will see the benefits in Massachusetts and follow suit. She adds that federal grants designed to promote quality improvement initiatives—State Innovation Model or SIM grants—will help fund these states’ efforts to adopt new, integrated approaches to integrating primary care with behavioral services.

“We know that the intersection of primary care and behavioral health takes on many different forms from embedded care, to co-located practices, to closely coordinated referrals.” Toppe added. “Behavioral health is a huge area of focus for state Medicaid programs and we expect to see greater expectations for coordination with primary care.”

So, congratulations to Massachusetts. Congratulations to the Bay State practices embarking on this new integrated approach. But how far behind can other states be? We’re betting, with this newly paved path forward, not too far at all.

So, we ask you the reader. Is there need for a similarly integrated approach in your state, in your hometown?