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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE II EXECUTIVE AND ADMINISTRATIVE OFFICERS
    OF THE COMMONWEALTH
  • CHAPTER 6D HEALTH POLICY COMMISSION
  • Section 14 Standards of certification for patient-centered medical homes; coordination of care; quality standards

Section 14. (a) By January 1, 2014, the commission, in consultation with the office of Medicaid, shall develop and implement standards of certification for patient-centered medical homes. In developing these standards, the commission shall consider existing standards by the National Committee for Quality Assurance or other independent accrediting and medical home organizations. The standards developed by the commission shall be based on the following criteria:

(1) enhancing access to routine care, urgent care and clinical advice though means such as implementing shared appointments, open scheduling and after-hours care;

(2) enabling utilization of a range of qualified health care professionals, including dedicated care coordinators, which may include, but not be limited to, nurse practitioners, physician assistants and social workers, in a manner that enables providers to practice to the fullest extent of their license;

(3) encouraging shared decision-making for preference-sensitive conditions such as chronic back pain, early stage of breast and prostate cancers, hip osteoarthritis, and cataracts; provided that shared decision-making shall be conducted on, but not be limited to, long-term care and supports and palliative care; and

(4) ensuring that patient-centered medical homes develop and maintain appropriate comprehensive care plans for their patients with complex or chronic conditions, including an assessment of health risks and chronic conditions.

(5) such other criteria as the commission deems appropriate.

In developing these standards, the commission shall consult with national and local organizations working on medical home models, relevant state agencies, health plans, physicians, nurse practitioners, behavioral health providers, hospitals, social workers, other health care providers and consumers. Furthermore, the commission shall consult with the department of public health to maximize opportunities for administrative simplification and regulatory consistency.

(b) Nothing in this section shall be construed as prohibiting a primary care provider, behavioral health provider or specialty care provider from being certified as a patient-centered medical home; provided, that such providers meet the standards set by the commission in accordance with this section or are recognized by the National Committee for Quality Assurance as a patient-centered medical home.

(c) Certification as a patient-centered medical home is voluntary. Primary care providers, behavioral health providers and specialty care providers certified by the commission as a patient-centered medical home shall renew their certification every 2 years under like terms.

(d) A primary care provider or specialty care provider certified as a patient-centered medical home shall have the ability to assess and provide or arrange for, and coordinate care with, mental health and substance abuse services, to the extent determined by the commission. A behavioral health provider or specialty care provider certified as a patient-centered medical home shall have the ability to assess and provide or arrange for, and coordinate care with, primary care services, to the extent determined by the commission.

(e) By July 1, 2014, the commission, in consultation with the office of Medicaid, shall establish a patient-centered medical home training for patient-centered medical homes to learn the core competencies of the patient-centered medical home model. The commission may require participation in such training as a condition of certification.

(f) For continued certification by the commission under this section, the commission may establish and monitor specific quality standards. Such quality standards shall be developed with reference to the standard quality measure set established by section 14 of chapter 12C.

(g) In providing after-hours care, a patient-centered medical home may enter into a cooperative agreement with another patient-centered medical home, primary care practice, limited service clinic, as defined by the department of public health, Medicare-certified home health agency for those patients that receive home-health services, or urgent care center to provide after-hours care for their patients.

(h) The commission shall develop a model payment system for patient-centered medical homes certified under this section or recognized by the National Committee for Quality Assurance as a patient-centered medical home. In developing the model payment system, the commission shall consider, but not be limited to, per-patient payments, payment levels based on care-complexity, and payments for care coordination, clinical management, quality performance and shared savings. Development of the model patient-centered medical home payment system shall be completed by January 1, 2014.

(i) Payers may make patient-centered medical home payments to network providers certified as a patient-centered medical home under this section or recognized by the National Committee for Quality Assurance as a patient-centered medical home, or equivalent. Payers may use the model payment system developed by the commission or any other medical home payment system the carrier deems appropriate.

(j) The commission shall develop and distribute a directory of key existing referral systems and resources that can assist patients in obtaining housing, food, transportation, child care, elder services, long-term care services, peer services and other community-based services. This directory shall be made available to patient-centered medical homes in order to connect patients to services in their community.

(k) Nothing in this section shall preclude the continuation of existing patient-centered medical homes or medical home programs currently operating or under development.