Fridays, noon - 1pm
Beginning in January of 2025, all practices applying or re-applying for PCPCH recognition will need to do so under the 2025 PCPCH Recognition Criteria. Program staff are hosting a webinar series to help practices understand some of the revisions and additions under the new model. This is a great opportunity to familiarize yourself with the new model and ask questions about specific standards! See upcoming sessions below and click here to see the full webinar schedule, register for more sessions, or view the recordings of previous ones!
Standard 4.E – Hospital Setting Transitions (August 23, noon-1pm)
 Research has shown that prompt follow-up of discharged patients is linked with reduced rates of readmission, emergency department use, and death. With this in mind, primary care partners have emphasized the value of developing defined processes around this type of follow-up. In this session, PCPCH Program staff will review some of the overall revisions to Standard 4.E under the 2025 model such as a new optional measure focused specifically on post-discharge follow-up procedures (4.E.2), and more flexible documentation requirements for the must-pass measure (4.E.0).
Standard 5.A – Population Data Management (September 6, noon-1pm)
 Being able to identify and group patients based on health status, conditions, or health behaviors allows primary care practices to more effectively manage the health of their patient population through outreach, reminders, follow-up, additional coordination, or other activities. Taking the additional step of incorporating data on patient demographics or health-related social needs (HRSN) into these efforts can help improve health equity and outcomes. In this session, PCPCH Program staff will review some of the overall revisions to Standard 5.A under the 2025 model such as a new optional measure focused on incorporating HRSN or demographic information into patients' risk scores (5.A.3), updates to the specifications for 5.A.1, and the change from a check-all-that-apply to a progressive standard.
Standard 5.B – Health Care Cost Navigation (September 20, noon-1pm)
 Cost of care can serve as a barrier to patients receiving primary care, adhering to recommended treatments, and establishing a trusting relationship with their medical home. State and National assessments have found that many patients delay or go without medical care due to cost concerns or uncertainty. In this session, PCPCH Program staff will review the addition of a new optional standard under the 2025 model which includes two measures focused on reducing these barriers by informing patients of low/no-cost preventive care services, increasing transparency with regards to the cost of visits, services, treatments, and medications, and assisting patients in navigating their payment options.
PCPCH Standard 3.D encourages PCPCHs to screen for their patients' health-related social needs. For those practices working on the Coordinated Care Organization Social Needs Screening and Referral metric, OHA has released additional guidance around screening for transportation needs. Screening questions must ask about transformation needs for both daily activities and medical appointments. OHA has updated the list of OHA-approved screening tools to indicate which tools cover the full breadth of transportation needs. See OHA Memo (July 31, 2024) for full details. The list of approved screening tools is also available here.
Submit by September 9
Centers for Medicare & Medicaid Services is hosting their 2024 Rural Health Hackathon event of collaborative sessions aiming to identify innovative solutions for rural health challenges, particularly access to care, care delivery, and workforce. In addition to in-person events, individuals and organizations in all U.S. states and territories may participate through the virtual idea submission process by September 9, 2024. Top concepts will be published in a CMS policy report!
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Questions?
We are here to help! Contact us at PCPCH@oha.oregon.gov
About the Patient-Centered Primary Care Home Program
Patient-Centered Primary Care Homes (PCPCHs) are health care practices that have been recognized by the Oregon Health Authority (OHA) for their commitment to providing high quality, patient-centered care.The PCPCH Program administers the application, recognition, and verification process for practices applying to become Patient-Centered Primary Care Homes.The program is also working with partners across Oregon to support adoption of the primary care home model. For more information visit www.PrimaryCareHome.oregon.gov.
The mission of the PCPCH Program is to be a trusted partner in primary care, collaborating with stakeholders to set the standard for transformative, whole-person, and evidence-based care.
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