To set forth recommendations to enhance the cultural effectiveness component of the 2011 National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) 2011 standards to assess the ability of a practice to function as a patient-centered medical home.
The concept of the medical home first emerged in the pediatric literature as a model to deliver primary care to children. In a 2002 policy statement, the American Academy of Pediatrics (AAP) expanded upon the concept to include the following seven operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. The Joint Principles for the Patient-Centered Medical Home, endorsed by the four primary care professional societies* was released in 2007, endorsing the concept of the medical home for not just children but for all individuals, as a cost effective way of delivering high quality care. Shortly thereafter, in 2008, the National Committee for Quality Assurance (NCQA), with the input of the four primary care professional societies*, developed a set of standards and process to evaluate and recognize practices implementing the medical home model. Since that time over 500 practices have been recognized as meeting the Physician Practice Connections©−Patient-Centered Medical Home© (PPC®-PCMH©) standards. This year, NCQA engaged in a collaborative process to improve upon their original standards to evaluate the medical home, for release of a 2011 version. What proves challenging to evaluate are those characteristics of the medical home relating to patient experience, such as compassionate and culturally effective care. The primary aim of this project was to set forth recommendations to enhance the cultural effectiveness component of the NCQA Patient-Centered Medical Home (PCMH) 2011 standards to assess the patient centered medical home.
A crosswalk, detailed side-by-side comparison, of existing standards for cultural effectiveness was performed to determine elements for inclusion into the medical home recognition process. The cultural effectiveness standards chosen to compare were the 1) nationally recognized CLAS (Culturally and Linguistically Appropriate Services) standards released by the Office of Minority Health (OMH), Health and Human Services (HHS) with the 2) NCQA 2010 Multicultural Health Care standards for health plans. Review of the literature, including policy statements, on the medical home was conducted to provide the rationale and background for inclusion of specific elements from the crosswalk. Data of existing practices being NCQA PPC-PCMH recognized (n=422) were evaluated to determine trends in achieving standards relating to cultural effectiveness by HHS region, practice size, and NCQA PPC-PCMH recognition level. Elements evaluated within those standards include but were not limited to: 1) Data collection on self identified race/ethnicity 2) Data collection on patient/family language preference and 3) Provision of language services when needed.
Twelve out of the fourteen OMH CLAS standards had a moderate to high degree of alignment with NCQA Multicultural Health Care standards. For these 12 standards, substantial evidence existed in the literature to support their inclusion into the medical home recognition process. Evaluation of data of existing practices achieving NCQA recognition as medical homes revealed regional variability in achieving elements relating to cultural effectiveness. Data revealed that a greater percentage of larger practices (5 or more) met these factor requirements, as compared to smaller practices. In addition, a greater percentage of Level 3 practices (highest NCQA recognition level) achieved these cultural effectiveness related elements as compared to Level 1 practices.
The medical home concept has advanced to the forefront as a leading model for providing high quality primary care. With policy moving forward to pilot and expand this model nationally, standards like the NCQA recognition program, will be vital to ensuring practices adhere to the key elements the medical home model prescribes. The variability seen amongst currently recognized practices in the area of cultural effectiveness suggests that current standards can be improved upon. Until basic data elements on race/ethnicity and language preference are collected uniformly across practices recognized as medical homes, we cannot begin to evaluate the impact this model has on reducing healthcare disparities and improving quality of care for all populations. A general summary of recommendations for the NCQA PCMH 2011 recognition standards, resulting from this evaluation, include the following:
- Data collection on language preference and race/ethnicity by practices must be made “Must Pass Elements” within the standards
- Performance Measures and Quality Improvement Data collected by practices must be stratified by race/ethnicity
- Standards should include elements on staff/provider trainings/education on cultural effectiveness
- Standards should include elements on staff/provider trainings/education on health literacy
- Standards involving patient experience survey data collection must ensure sampling methods capture vulnerable populations
Johann Chanin, R.N., M.S.N., Director of Product Development, NCQA and Sarah Hudson Scholle, M.P.H., Dr.P.H., Assistant Vice President, Research and Analysis, NCQA
American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Osteopathic Association (AOA)