Texas Medical Home Initiative

The project attempts to facilitate increased clinical quality and efficiency, improved patient and physician experience of care, and overall care coordination and integration within and among the participating practices. The project will begin with a small scale implementation. Based upon “lessons learned” during the first 12-18 months of this implementation, the project will be expanded. During Stage One, the focus will be primarily on adults; however, the project will also include patients younger than 18 with severe asthma.

In addition, there will be a focus on young adults with special health care needs aged 14-24 if transferring from pediatric practices. Stage One will be limited to practices that treat adult patients or both child and adult patients in which the medical home team leader is a primary care physician within one of three practice types: one large primary care practice, two small to medium (2-7 practitioners) primary care practices or one multi-specialty and/or integrated practice. Selected practices will have a six month “ramp up” period to achieve the qualifications required to initiate payment: • NCQA Level 1 recognition • 24 hour/7 day access • Establishment of a patient registry • Implementation of evidence-based protocols • Establishment of service agreements with defined specialty practices and at least one frequently referred-to hospital • Agreement to assist in providing relevant patient claims and defined additional clinical information to the TMHI project • Participation in the special needs transition program.