Population Health: The Patient Centered Medical Home

As the country continues to hurtle towards value-based care and population health, no greater asset to the cause has risen than the Accountable Care Organization. However, where did the ACO originate from? The foundation of ACOs can be found in Patient Centered Medical Homes (PCMH) where the idea of transforming healthcare to be population health-focused all began.

At the core, a PCMH is tasked with coordinating care for patients whereby their primary care providers work alongside each individual to make sure they’re getting the best possible care. Think of a good PCMH as a quarterback: they call the plays, and they determine the course of action all the while helping you navigate the obstacles that are in front of you. If they think a course correction is needed, it’s up to them to call an audible on your behalf. Everyone else in your health network represent the other players on the field.

Quarterback throwing a football in a professional football game
Think of a PCMH as a quarterback.

When patients are referred to a specialist by their primary care physician, the PCMH ensures transparency between that provider and their practice. During hospital visits, the PCMH steps in to ensure that the patient follows up with their Primary Care Physician (PCP) upon discharge. According to the National Committee for Quality Assurance (NCQA), there are approximately 13,000 practices, with 67,000 clinicians, that are recognized as a Level 1, 2, or 3 PCMH. The NCQA has found that these organizations are statistically proven to build better patient-provider relationships, which lead to better quality of care and reduced healthcare costs. Accountable Care Organizations would be wise to partner with these forward-thinking practices as they share a common goal, and navigate the same treacherous waters of rising costs, stagnant reimbursements, and frustration with a payment system that rewards volume over quality.

NCQA certification for a PCMH is a painstaking process whereby the practice has to prove that they are able to reduce fragmentation through team-based care, improve the patient experience through surveys, manage chronic conditions effectively, and improve access to care. Healthcare effectiveness Data and Information Set (HEDIS) measures are taken into consideration, and the NCQA requires continual process improvement. Other organizations, such as the American Academy of Family Physicians, assist practices with acquiring NCQA certification. As population health requires solid relationships as the foundation of care, these are all areas of opportunity for today’s ACOs to take advantage of as they continue to grow towards two-sided risk following CMS’s Pathways to Success Final Rule.

Premier Family Health & Wellness, near West Palm Beach, Florida, is an excellent example of a high quality, experienced PCMH. Founded by husband-and-wife Drs. Vincent M. Apicella and Mariaclara E. Bago, Premier has built itself into a multi-modality facility whereby the community can access the majority of their healthcare needs in one location. Premier features primary care, an urgent care for same-day medical needs, a dental office, a wellness center, limited imaging such as x-rays, and they’ve even built a café to provide food and drinks since some patients will take the entire day off of work to take care of everything at once. It’s the “one stop shop” piece that Drs. Apicella and Bago were adamant about when they first opened in 2004.


Dr. Apicella

Taking care of ‘All Your Medical Needs, All In One Place’ has become our corporate mantra for a reason. It serves the two most important areas of need in our healthcare system today. First, it provides an extraordinary level of care and access for the patients we serve, and second, it helps to prevent over-utilization of healthcare dollars. We believe in our model and our outcomes substantiate this blueprint to serve as the future of primary care.

Dr. Apicella

With six physicians on staff, and a mix of eight ARNPs and physician assistants, Premier ensures their patients are seen by care teams to ensure accountability. It isn’t unusual for one provider to double-check with another provider for an immediate second opinion if one is required. The Nurse Practitioners and Physician Assistants are able to bolster care by handling the majority of the basic services required, such as annual physicals or treating common colds and flu symptoms. The team of providers entrenches themselves in the local community such that they get to know the specialists and hospitals in the surrounding area. They take pride in being experts in their part of Palm Beach County so that their patients aren’t seeing other doctors whom may provide subpar quality. As they are affiliated with Palm Beach ACO, it’s no surprise who the highest performing Accountable Care Organization in the United States is.

Recently Premier also became one of the first medical practices to promote a nurse practitioner to the administrative role of Chief Medical Officer. Elizabeth S. Lofaso, ARNP has an education from the University of Florida and decades of experience. For her, joining a Patient Centered Medical Home in 2005 was an easy decision because she already understood the impact of practicing good population health from working so closely with her patients.


Elizabeth S. Lofaso

As a Registered Nurse with years of inpatient experience, a patient-centered approach was not a foreign concept. As I transitioned into the outpatient primary care setting as an Advanced Practice Nurse, it became clear that preserving that patient-centered approach would pose a challenge. Primary care providers are heavily tasked with reporting and documentation requirements that can easily shift one’s focus away from the patient. PCMH recognition is not easy to achieve, but it is worth the effort as we transition the focus back onto the patients who seek our care, says Lofaso. A PCMH places the patient in the spotlight and encourages the development of a true medical home. It requires providers to strengthen relationships with their patients, families, local hospitals, specialty providers and with their own staff members. Every team member is critical to the success of a medical home. When the primary care provider commits to a patient-centered approach, everybody wins.

Elizabeth S. Lofaso

It’s interesting to note that there is no data specifically relating to the number of PCMHs that are affiliated with ACOs. However, if the NCQA is accurate about their 13,000 PCMH claim (the URAC and the Joint Commission also have their own PCMH certification processes), it’s likely that there are many whom are still unaffiliated.

ACOs are being pushed to take on more risk, and some are scrambling to find the right balance of providers. Considering how like-minded the Medical Directors of PCMHs are to ACO administrators, wouldn’t aligning with these practices seem like a championship decision?


Ryan Mackman

About the Author


Ryan Mackman, MBA, MHA - Business Consultant

Ryan Mackman has been an ACO business consultant team member with Salient since March 2018. In this role, he acts as a solution trainer, marketing and sales consultant, as well as Value Based Payment strategist. His skillset helps augment Salient’s efforts at the ACO and physician practice level. Prior to joining Salient, Mr. Mackman spent four years as the Business Administrator and Project Manager for Premier Family Health, a Level 3 Patient Centered Medical Home near West Palm Beach, FL. Mr. Mackman holds a Master’s in Business Administration and a Master’s in Health Administration from Florida Atlantic University. He received his Bachelor’s degree from the University of Florida. He currently holds a Six Sigma Green Belt Certification and is a member of the American College of Healthcare Executives.

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