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Patient Centered Medical Home Initiative

Community Education Events

The PCMH Initiative, an ongoing quality improvement project of the Safety Net Clinic Coalition of Santa Cruz County (SNCC), reaches a broader audience of providers and fosters cross-sector relationships by offering Continuing Medical Education presentations featuring national and local experts. These experts have presented on various topics relating to the PCMH model including integrating behavioral health and primary care and using data to drive PCMH transformation.
These community education events are sponsored by the Central California Alliance for Health (CCAH).

Patient Centered Medical Home 101
May 26, 2011

On the afternoon of May 26th, a panel of local physicians presented and discussed their experiences with implementing and advancing PCMHs within their various practices. Each of the Patient Centered Medical Home 101 presentations focused on a component(s) of the PCMH model and their experience implementing these components.

  • Mike Conroy MD, Palo Alto Medical Foundation (PAMF), focused on enhanced access, team-based care and patient-centered care, which includes a patient advisor program, at PAMF.
  • David Simenson MD, Golden Valley Health Centers (GVHC), described empanelment at GVHCs which included disease registries for diabetes, hypertension and warfarin patients.
  • Caroline Kennedy MD, Monterey County Health Department focused on care coordination within Monterey Country clinics by integrating primary and specialty care.
  • Nancy Greenstreet MD, Physicians Medical Group of Santa Cruz County (PMG), explained how PMG clinics see all patients within 0-2 days of request through enhanced access programs.
  • Richard Helmer MD, Central California Alliance for Health (CCAH), discussed how CCAH uses provider payment incentives that reward quality patient care to advance the PCMH within contracted clinics.

On the evening of May 26th, several national experts also discussed their experiences with advancing PCMHs. Xavier Sevilla MD, FAAP, from Whole Child Pediatrics in Florida, presented his practice's transformation into a PCMH and the results of this transformation. David Labby MD, PhD and Rebecca Ramsay BSN, MPH, both from CareOregon, presented data from numerous CareOregon clinics that are transitioning towards PCMHs. These presentations detailed the positive outcomes of the PCMH model of care such as increased patient health and satisfaction, decreased patient hospital stays and decreased costs.

Integrated Mental Health Care: Improving Lives through Effective Collaboration
October 27, 2011

Featured Speaker: Jürgen Unützer MD, MPH, MA; AIMS Center at University of Washington

Jürgen Unützer MD, MPH, MA discussed models, outcomes and the importance of integrating behavioral health and primary care in Integrated Mental Health Care: Improving Lives through Effective Collaboration. The bi-directional effects of behavioral health and physical health suggest a need for greater integration between these services. Integrating behavioral health and primary care increases access to behavioral health care, treats the 'whole patient' and ensures that patients get better.  In randomized clinical trials, integrated health care systems saw improved patient satisfaction with depression care and increased effectiveness of depression care. Integrated systems are also associated with lower total health care costs. Unützer also discussed the principles of integrated health care and collaborative team approaches to care.

SBIRT Training: Performing SBIRT in the Medical Home
November 17, 2011

Featured Speaker: Jim Winkle MPH; SBIRT Oregon Primary Care Initiative

Jim Winkle MPH presented the SBIRT method of addressing alcohol and drug use within the primary care setting in Performing SBIRT in the Medical Home. SBIRT stands for screening, brief intervention, and referral to treatment- an evidence-based, effective method to intervene in alcohol and drug misuse within the context of a primary care visit. SBIRT has been developed to be implemented into the PCMH.  This training focused on enhancing provider's brief intervention skills to address patient's behavioral health issues. Implementing SBIRT has been demonstrated to result in a 10-30% reduction in alcohol consumption at 12 months, fewer hospitalizations and ER visits and cost savings.

Using Data to Drive PCMH Transformation
May 9 and May 10, 2012

Featured Speaker: Carolyn Shepherd MD, Clinica Family Health Services, Colorado

Carolyn Shepherd MD discussed how Clinica Family Health Services uses data to inform quality improvement projects in Using Data to Drive Patient Centered Medical Home Transformation.  Dr. Shepherd explained that Clinica uses various types of data for quality improvement including direct data, data for decision support, patient and population data, and outcomes improvement data. Clinica uses these different types of data to create a care plan tool for providers and patients that includes the patient appointments, vitals, medications, a problem list, labs and self-management goals.  Clinica also uses patient centered registries that include patient demographics, outreach details, and patient care alerts. Registries enable Clinica staff to optimize team based care. Dr. Shepherd suggests using individual patient data, delivering data over time, and breaking out data into important populations to validate data and increase staff buy-in. 

Building Blocks of High-Performing Primary Care
November 29, 2012

In Building Blocks of High-Performing Primary Care Tom Bodenheimer MD, Co-Director at the Center for Excellence in Primary Care at UCSF, discussed how strengthening primary care through team-based care can help address the national and local primary care provider shortage. Dr. Bodenheimer suggests that doctors alone aren't the answer to this problem, so we have to find ways to "share the care." Across 23 high-performing clinics UCSF studied, one of the most important characteristics was their ability to increase their capacity without necessarily increasing the number of clinicians.  Clinics did this by sharing care responsibilities across a team of people who work together closely, with patients assigned to a clinician/medical assistant team. Teams are responsible for a set number of patients, and work to improve the health of their assigned group of patients. A team care approach increases efficiency, dramatically improves continuity of care for patients, and builds trust between patients and doctors.

Additionally, Dr. Bodenheimer described how medical assistants can make sure that patients are getting preventive care, such as scheduling check-ups and screenings.  Team members - and patients themselves - can serve as health coaches to provide the time-consuming and necessary support for changing behaviors.  All of this frees up physician time and allows other team members to contribute, which increases our capacity to provide primary care. 

Community Education Events supported by


Community Education Event Presentations

PCMH 101
PCMH Program on Community TV

Integrated Mental Health
Integrated Mental Health Program on Community TV

SBIRT Training

Using Data to Drive PCMH Transformation

Building Blocks of High-Performing Primary Care
Building Blocks Program on Community TV