Developing a PCMH program



Mid-Ohio Valley Medical Group (MOVMG) is a private practice that consists of sixteen family medicine physicians, four nurse practitioners, and 110 employees. The practice serves approximately 45,000 patients in West Virginia and Ohio through a main office in Vienna, West Virginia, and a smaller office in Belpre, Ohio.

MOVMG had considered seeking Patient Centered Medical Home (PCMH) certification as early as 2010, when they began to understand how the elements and standards of NCQA PCMH could benefit the practice. In 2012, MOVMG chose to apply inventive revenue from quality improvement programs towards a PCMH project for the whole practice population. Coming changes to value-based care reimbursement also influenced their decision to move forward.

After the practice made the decision to move forward, they began the process by choosing to focus their attention in three areas where it believed it could make the largest impact on morbidity and co-morbidity within their population: diabetes mellitus type 2, hyperlipidemia, and tobacco addiction .For the health maintenance measure, the practice chose to focus on: promoting the shingles vaccine to reduce the incidence and/or severity of shingles; improving early detection of breast cancer by educating and encouraging our patients to receive regular mammograms; and encouraging Medicare beneficiaries to get their Medicare Wellness Exams.


In January of 2015, the practice achieved NCQA PCMH Level 3 Recognition.

MOVMG began its process by providing education for physicians and staff about the definition, ideals, and benefits of PCMH. In reviewing the concepts, standards, and elements of PCMH, the practice discovered that while it lacked necessary written policies and procedures, in many ways it already performed like a PCMH. The practice also found that its staff was already meeting many of the PCMH requirements, although those requirements and related tasks were not adequately delineated in job descriptions.

Physicians and staff worked collaboratively to build a program framework and used existing office flow patterns to better define its PCMH program. The practice integrated education with new policy rollouts,  and developed templates, gap reports, standing orders, and patient reminders to assist the doctors and nurses in applying these policies without adding a significant time burden. The practice also implemented tracking procedures for labs and radiology studies to ensure that patients participated and that results were delivered back to the practice.

Beyond the internal workings of the practice, MOVHG reached out to the local hospitals to improve communication in transition of care situations. With improved coordination, the practice now contacts patients to schedule a follow-up appointment at time of discharge, and works to ensure the receipt of any needed records. The practice also implemented improved referral tracking procedures to ensure that specialists receive the patient data they need, and in turn, send information back to the practice after patient visits.

The practice has seen some of its greatest improvements in patient communication. Its web site features a great deal of information for patients, and offers them the ability to print off required paperwork to complete prior to their office visit. The site features a calendar with group classes and special events such as flu shot clinics. The practice also promotes its activities and general health information through Facebook. Many patients take advantage of the practice’s secure web portal to access their records, communicate with physicians, and request prescription refills.

Lessons Learned:

MOVHG discovered that pursuing PCMH certification and managing its program involved several new costs, which while justified, did have an impact on the organization and its productivity. First, the practice brought on a new RN-level staff member to serve as patient care coordinator. Until the practice can justify adding a social worker and a dietician, nursing staff have taken on the responsibilities of those roles, reducing the time available for their core responsibilities.

Similarly, the training requirements and incorporation of new PCMH workflows have also had an impact on productivity.

Next-Steps/Future Vision:

MOVHG is proud of its program and can identify improved patient outcomes in many areas, as well as improved patient accessibility. The practice solicits feedback and suggestions from patients, staff, and providers, and continues to develop and improve its PCMH.

Success Story Topic
Health Info Technology
Patient Centered Medical Home