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Patient Centered Medical Home Initiative

Safety Net Clinic Coalition Breakthrough Series

The Patient Centered Medical Home (PCMH) Initiative is an ongoing quality improvement project of the
Safety Net Clinic Coalition of Santa Cruz County (SNCC) to prepare for coverage expansion through the Affordable Care Act in 2014. The PCMH Initiative follows the IHI Breakthrough Series model for improvement which includes learning sessions, webinars and direct clinic team coaching facilitated by HIP staff and outside experts. SNCC clinics have established quality improvement teams that work to strengthen their clinic's capacity to provide medical homes through individualized improvement projects.
This Initiative is funded in part by the Blue Shield of California Foundation (BSCF) and the Central California Alliance for Health (CCAH).

The PCMH Initiative strives to implement the following components of the PCMH model of care within SNCC clinics:

  • Empanelment: linking patients to a provider or care team.
  • Team-Based Care: care teams within clinics work together to provide quality care to all patients.
  • Patient Centered Care: patients are encouraged to take an active role in their care and treatment.
  • Enhanced Access: structuring clinic hours to reflect appointment demand, offering same day appointments, and performing chronic and preventative services at every visit.
  • Care Coordination: integrating behavioral health, specialty care and primary care services and partnering with community resources.
  • Effective Leadership: providing visible and sustained leadership committed to supporting a culture of quality improvement; providing resources for teams to implement appropriate practice changes; and redesigning compensation.
  • Quality Improvement: training staff in quality improvement methods, using data to track progress of improvement projects and altering projects as necessary.
  • Organized, Evidence-Based Care: utilizing evidence-based care processes throughout patient care in a standardized manner.

PCMH components adopted from the Qualis Safety Net Patient Centered Medical Home Initiative (

The PCMH Initiative reaches a broader audience of providers and fosters cross-sector relationships by offering Community Education Events featuring national experts presenting various topics relating to the PCMH model including integrating behavioral health and primary care and using data to drive PCMH transformation.


PCMH Initiative Faculty

Neal Adams MD, MPH, California Institute of Mental Health
Vicki Amon-Higa, Amon-Higa and Associates
Tom Bodenheimer MD, UCSF Center for Excellence in Primary Care
Mike Conroy MD*, Sutter/PAMF
Amireh Ghorob MPH, UCSF Center for Excellence in Primary Care
Craig Giraudo, Amon-Higa and Associates
Kent Imai MD, Community Health Partnership
Eleanor Littman MSN*, HIP
Barbara Palla MD*, HIP
            *Returning 2011 coaches.


PCMH Initiative Events

Learning Session 1 - May 27, 2011

Featured Speakers:
David Labby MD, PhD,
Rebecca Ramsay BSN, MPH, CareOregon
Xavier Sevilla MD, FAAP, Whole Child Pediatrics, FL

In their presentation, Primary Care Renewal, David Labby MD, PhD, and Rebecca Ramsay BSN, MPH, discussed how to create a new primary care system paradigm shift from a physician centered medical system restricted by payment models to a patient centered medical system with incentive payment models that focus on population health. Labby and Ramsay described this shift as one "from historical (craft) practice to intentional, self-reflective, collective practice". Labby and Ramsay also discussed how CareOregon, a state funded Medicaid health plan, has implemented PCMH transformation projects within participating clinics and the successful outcomes of these projects. These projects include proactive outreach to patients and open access and were associated with a greater number of patients with blood pressure under control and decreased hospital stays.

In Transformation into a PCMH: The View from the Trenches, Xavier Sevilla MD presented his experiences developing a PCMH within the Whole Child Pediatrics Clinic. Sevilla also described the PMCH model as a paradigm shift in medical care including the shift from individual to population care, physician to team-based care, episodic to continuous care, episodic payment to comprehensive payment, and from clinic centered to patient centered care.  Sevilla implemented enhanced access through same day appointments and decreased wait time, created care teams, a system of emailing patients and conducting outreach calls and created a registry and individualized health plans for patients with asthma in the process of PCMH transformation.

Learning Session 2 - November 18, 2011


Featured Speakers: 
Wendy Bradley LPC, Southcentral Foundation, Anchorage, AK
Christopher Campbell PA, Southcentral Foundation, Anchorage, AK
Brenda Goldstein MPH, Lifelong Medical Care

The PCMH Initiative Learning Session 2 focused on integrating behavior health care and physical health care within the PCMH.  Throughout this day-long learning session, clinic teams heard presentations from various experts on behavioral health integration, participated in team exercises and planning sessions, and presented the progress of their improvement projects to date.

In Achieving Behavioral Health Integration in Primary Care Transformation, Wendy Bradley LPC and Christopher Campbell PA presented various methods for integrating behavioral health and primary care. They also discussed the key elements of the behavioral health integrated model at the Southcentral Foundation and reviewed outcomes of this integrated behavioral health program.  Important outcomes from this program include:

  • 77% of Primary Care clinic staff reported increased efficiency;
  • 88% of Primary Care clinic staff are more satisfied with their job;
  • A 91% increase in patient access to Behavioral Health services; and
  • A reduction in anti-depressants and narcotic medication and lab orders.

Brenda Goldstein MPH
, the Psychosocial Services Director at Lifelong Medical Care, presented the Partners in Health: Primary Care/County Mental Health Collaboration Tool Kit, a publication of the Integrated Behavioral Health Project (IBHP) as well as the IBHP website ( Goldstein reviewed and discussed how to utilize these resources.

Learning Session 3 - May 11, 2012
Keynote Speakers:
Carolyn Shepherd MD, Clinica Family Health Services, Colorado
Sharon Tapper MD, CMS Innovation Advisor

In Patient Centered Medical Home: Transforming Patient Experience, Carolyn Shepherd MD discussed the transformation process of Clinica Family Health Services, a FQHC clinic system based out of Denver, Colorado.  Clinica focused on 6 key redesign initiatives to improve patient centered population based management including continuity, access, improved care delivery model, improved office efficiency, improved technology design, and patient activation and self-management.  Clinica uses the chronic care model, the IHI Model for Improvement and PDSA cycles to structure redesign projects. Clinica also frequently analyzes data to track the progress of their redesign projects. Dr. Shepherd explained that these redesign initiatives improve the quality of care and health outcomes for patients. 

Sharon Tapper MD, a CMS Innovation Advisor, described the 5 skills needed to become a disruptive innovator in How to Be a Disruptive Innovator.  The 5 skills are associating, questioning, observing, networking, and experimenting. Dr. Tapper explained associating as the cross pollination of ideas, questioning as crafting the right question to accomplish work, observing  as looking for the job to be done, networking as expanding the diversity of colleagues, and experimenting as piloting new ideas.

Breakout Session Speakers:
Neal Adams MD, MPH, California Institute of Mental Health
Vicki Amon-Higa, Amon-Higa and Associates
Mike Conroy MD, Sutter/PAMF
Amireh Ghorob MPH, UCSF Center for Excellence in Primary Care
Carolyn Shepherd MD, Clinica Family Health Services, Colorado

Amireh Ghorob MPH presented Teams in Primary Care: Share the Care: From I to We. Amireh discussed how using teams in primary care is an effective way to ensure that patients receive important chronic and preventative care. The composition of teams can vary depending on the needs and size of a practice. Some teams may be just a primary care provider and a medical assistant while others may include a primary care provider, nurse, and two medical assistants.   

In Primary Care Redesign: Tracking Performance Data to Drive Change, Mike Conroy MD and Vicki Amon-Higa discussed the redesign process of the Palo Alto Medical Foundation (PAMF).  Mike and Vicki discussed PAMF's work to improve workflow by creating medical assistant rooming standards and tracking and displaying the results of rooming standards.  PAMF also works on similar improvement projects focused on outreach for chronic disease patients and office efficiency.

Neal Adams MD, MPH discussed various methods for improving the integration of primary care and mental health services.  Neal presented several guidelines for improved integration including creating a continuum of care, identifying care settings, facilitating transitions between primary care and specialty mental health care, and determining the level of care for patients.

Carolyn Shepherd MD explained the process for becoming PCMH recognized by the National Committee for Quality Assurance (NCQA) in Pit Stop: Application for Patient Centered Medical Home Recognition.  Dr. Shepherd discussed planning steps, the application process, and tips for creating a good NCQA-PCMH Application. She also reviewed the overlap between PCMH recognition and Meaningful Use. Dr. Shepherd explained that Clinica's application and PCMH recognition pushed Clinica to continue quality improvement work.

Learning Session 4 - November 30, 2012

Keynote Speakers:
Bonni Brownlee MHA, CPHQ, CPEHR, Qualis Health
Tom Bodenheimer MD, Center for Excellence in Primary Care, UC San Francisco

In The Case for PCMH in the Safety Net, Bonni Brownlee reviewed the Qualis change concepts for practice transformation and the components of the PCMH model of care. Brownlee also discussed outcomes and lessons learned from the Qualis National Safety Net Medical Home Initiative.  National outcomes from PCMH implementation include: decreased disparities in access to primary care, cost savings from reduced hospitalizations and ED use, better chronic illness care, more preventive care and greater provider satisfaction.  Brownlee suggested that engaged leadership, the importance of measuring progress and the value of peer mentoring as key lessons learned from the national initiative.

Tom Bodenheimer MD described the aspects of team-based care in The Components of High-Performing Teams in Primary Care.  Team-based care is an important step to increasing clinic capacity to provide greater access to care. By sharing patient care among a team that includes providers, medical assistants, nurses, pharmacists, and potentially others, clinics can provide quality care to a large number of patients.  Dr. Bodenheimer also discussed the importance of linking patients to a team through empanelment; empanelment is foundation for team-based care.

Breakout Session Speakers:
Tom Bodenheimer MD
Bonni Brownlee
Amy Peeler MPH, Chief of Santa Cruz County Health Services Agency Clinics

Bonni Brownlee discussed the relationship between empanelment and clinic capacity in Empanelment: Using Panel Data to Understand Capacity.  Empanelment is a systematic way to ensure that every patient has an assigned primary care provider and a care team. Brownlee reviewed how to calculate an appropriate panel size for a provider and calculate the supply and demand for appointments at a clinic. A clinic can increase capacity, if there is greater demand for appointments than supply, by assuring provider panels are the right size, adding new staff positions, and opening or closing panels to new patients.

Tom Bodenheimer MD introduced the concept of training Medical Assistants (MA) to be health coaches and the relationship to team-based care in MAs and Team-based Care: Introduction to Health Coach Training. Health coaching is a way to interact with patients and engage patients in their care. By training MAs to be health coaches, MAs can help patients understand the provider's advice and work with patients to use the advice to improve their health.

In Coleman Rapid DPI: View from the Trenches, Amy Peeler MPH reviewed the process and outcomes of the Coleman Rapid Dramatic Performance Improvement (DPI) at the Santa Cruz County Emeline Clinic. Rapid DPI is an intensive, data-driven, patient-centric process improvement program. The Coleman team uses process improvement best practices to better care coordination, improve patient/staff experience, while enhancing outcomes and improving efficiency. Rapid DPI aims to improve daily operational activities while creating greater organizational transformation.


Participating SNCC Clinic Teams

Cabrillo College Student Health Services
Diabetes Health Center
Dientes Community Dental Clinic
Planned Parenthood Mar Monte Westside
Planned Parenthood Mar Monte Watsonville
Santa Cruz County Emeline Clinic
Santa Cruz County Homeless Persons Health Project
Santa Cruz County Mental Health and Substance Abuse
Santa Cruz County Clinical/Public Health Collaborative
Santa Cruz County Watsonville Health Center
Salud Para La Gente
Santa Cruz Women's Health Center

PCMH Initiaitve supported by


PCMH Initiative Presentations

Learning Session 1 

Learning Session 2

Learning Session 3
Shepherd (Keynote)
Shepherd (Breakout)

Learning Session 4
Brownelee (Breakout)

Team-based Care Workshop
Powell & Chibras

Share the Care
Pre-Clinic Huddles Worksheet

Panel Management Training
Health Coaching in Spanish
Joy at Work Quiz

Patient Engagement
Presentation and Audio


Community Education Event Presentations

CHCF PCMH Initiative Report