- 700 bed hospital and health system
- 19 primary care locations
- 70 primary care providers


- Achieve PCMH Recognition and setup case management
- Expanded to: project management, reports and analytics, Pharm-D and strategic advisory services.


- All primary care locations received PCMH Recognition
- Large reimbursement increase
- Stronger negotiating power within hospital and community
- Built foundation for an ACO
- Quality focused outlook on health care delivery
- Visible improvement in their QRUR report after 12 months


Healthier through Data

This health system’s practices noticeably improved quality measures, saw visible improvement in their QRUR report, and boosted their reimbursement rates while achieving PCMH Recognition within just ONE year. 

Executive Summary

Managing patient population’s health and gaining PCMH Recognition has never been more achievable. Let’s focus on a health system with approximately 20 primary care locations, including family medicine, internal medicine and pediatrics. This client needed Recognition fast, but they were unaware of other opportunities for financial, quality and patient gain until Clarify started working with them.  

This health system client contacted Clarify requesting assistance in gaining NCQA Patient Centered Medical Home (PCMH) Recognition for all three of their primary care divisions - in total approximately 20 locations. After a few meetings, agreements were signed, and this organization became a Clarify client. 

Leadership at the health system indicated a strict and aggressive internal deadline on this project, so Clarify needed to work quickly and efficiently. Clear, frequent updates and communication on timelines and deadlines was a critical factor for the success of the project.

PCMH Recognition Process

The client was a multi-site application with NCQA, so the corporate portions of the PCMH application and submission were completed first. Clarify then began working with the different locations and they were prioritized by size and readiness. Timelines were established for items, tasks, and deliverables to be completed which streamlined the PCMH Recognition process. Clarify worked closely with their internal assets and people to get this all done. PCMH Recognition was achieved in all locations. The project quickly expanded to include consulting in project management, reports and analytics, case management and strategic advisory services. Gap analyses were performed throughout the project to determine areas in need of improvement.

Population Management and EHR Optimization

What started as a simple request to get PCMH Recognition soon evolved to include Population Health Management. Population Health Management, “involves the design, delivery, coordination, and payment of high-quality health care services to manage the populations we identify while using the best resources available.” (Institute for Healthcare Improvement, 2014). This organization was aware of the benefits that population health management held, both to the patients as well as the organization. Clarify’s focus shifted to patient engagement. A case management department was started, case managers were hired, and a Pharm-D and RN Nurse Leader was later added to the team. These activities allowed Patient Outreach processes to be implemented. The Patient Outreach processes enabled providers and the care team to keep in more frequent contact with their patients ensuring that appointments were kept and treatments were followed. Clarify’s research has shown that by keeping in contact with patients, health is improved and spending is ultimately reduced.

"We were missing a lot of stuff"

- our Client

The health system already had a top notch EHR system-they just needed to use it wisely and get information and reports into the hands of people making decisions. What data and reports, how frequently and who needs the data is mission critical. Clarify helped the client make decisions to create for providers to document, report, and analyze patient data. The use of data is critical to Population Health Management (and plenty of other things, by the way. It enables providers to find trends in a patient population, which can determine the most effective and efficient treatments for the population in question. The use of the now available data and the shift towards practicing Population Health Management has allowed this health system to greatly improve their patients’ health outcomes. 

Strategic Advisory Services

COMMunication is key

There wasn’t enough effective and coordinated communication between the different entities of this primary care health system, and this needed to change. Different groups were requesting similar reports to be run from corporate, and it was in their best interest to combine efforts and unify and streamline their requests. Clarify assisted in their assembling a PCMH “task force” comprised of leaders from each entity to make these unified requests as one group. This task force was necessary because of this particular client’s size, and it turned out to be truly beneficial in their progress and opening communication lines for future progress in which was in their mutual best interest. 

Project Outcomes

“We were able to configure our PCMH and case management programs in a way that worked for us and our budget, but was more cost effective than other complex models. Clarify helped us do that.”    
- our Client

After working with Clarify, the health system has experienced quality improvement in both process and outcome measures, and their reimbursements have been positively impacted. In just one year from their project start date, the health system witnessed the effect that PCMH can have on an organization. 

Their Medicare quality metrics improved: their position on the CMS QDR Scatter Plot Grid, a series of quality metrics tied reimbursement rates, has gone from the bottom left quadrant to the top right - a drastic rate increase in just ONE year! The client said it was a visually noticeable difference. 

PCMH related activities like routine Diabetic Foot Exams, monitoring A1C and increasing medication reconciliation have also resulted in noticeably improved patient health. Clarify helped this health system add some processes, verification, checks and enhance the focus on quality. Before the transformation, there was the mentality of assumption that the care being delivered was good. 

“Our partnership with Clarify and the hard work we've done has changed the way we do business.”    
- our Client

PCMH Recognition has given the health system the ability to negotiate contracts with both government agencies and manufacturers. They have since secured a government contract with the city where they’re located. Also, the health system now has more internal control and ability to document and execute additional  PCMH related initiatives such as TCM, CCM and Care Coordination. This project has paved the way for them to transition to volume to value reimbursement, starting the path for this health system client to become an ACO. Overall, Clarify’s work opened the door for higher reimbursements and greater patient health outcomes for this health system.



- 7 location, pediatric group
- Over 30 providers  
- Privately owned                                                         


- Achieve PCMH Recognition
- Capitalize on payment structure
- Strategic advisory services


- Improved reporting and booking processes
- Prevented hiring of unnecessary staff
- Utilization of available data and reporting capabilities


Putting it all together

At Clarify, we are here to offer support and guidance to healthcare organizations looking for up-to-date, forward thinking and effective ways to deliver care and receive reimbursements. This particular pediatric group was innovative and aware of the benefits that Patient Centered Medical Homes and population health management could bring to their patients and the practice. We quickly learned, this was a capable and determined work group with strong leadership, and that they recognized the benefits that come from working with Clarify because we’ve done this before, and can save them critical time, money, stress and help them avoid mistakes. 

This pediatric group, an independent, multi-site practice began the project as a well structured, critically thinking, and team oriented group. They were experiencing negotiation issues in their current contracts with health plans. Aware of the coming shift to value based reimbursements, they sought to stay ahead of the curve. They achieved Meaningful Use and decided to become PCMH Recognized, do more population health work, and refine some of their processes to streamline care and improve documentation. Their wisdom and effort gave them more leverage in negotiations to increase their revenues as well as made them a more attractive partner to health systems, clinically integrated networks, and ACOs in their region. Since all sites were generating Meaningful Use reports and working as teams, PCMH Recognition and process restructuring/implementation moved forward at a fast rate.

The Process

Where We Started

A small, effective workgroup was identified to take on this project for the group. While they have multiple locations, many operations are performed by their small corporate team. Let’s be clear, this isn’t a massive company with tons of excessive resources. Each team member brought unique talent and perspective to the workgroup. The group was intentionally kept small, and kept a focus on work, not just discussion. This is an important point - the emphasis was on progress and getting things done. If a point required discussion, they talked about, made decisions and kept things moving. So often we see people get stuck in meetings with no end and no point. 

Clarify began this project by meeting with the workgroup to explain the process and what to expect. The kick-off meeting went well, and allowed everyone to be on the same page. In order to submit the necessary reports and documents to NCQA, deadlines were established to have tasks, reports and documentation completed for review by Clarify. They used Clarify’s PCMH project management tool. Tasks were assigned for one to two people who had the knowledge and TIME to complete these tasks, which allows for accountability. The workgroup had a set meeting once a week, and the team lead had a standing weekly call with their Clarify project manager to ask questions, provide updates and get a status update from Clarify. Sometimes the full team attended this call, but only when necessary. Everyone’s time is valuable, and everyone on the team had other responsibilities also. The team meetings allowed for group discussion to be answered and requests to be met efficiently, greatly reducing the Recognition time. The workgroup asked Clarify questions as they had them and involved us when they got stuck, or thought they may be misunderstanding or complicating something.

Ambiguity can cost you thousands

Clarify made a few small recommendations early on to the team. One, the team thought they needed to hire a registered nurse (RN) in order to even begin and have a meaningful PCMH program, an expensive professional to add to a pediatric or primary care practice for a mostly administrative role. We explained more affordable alternatives, ways to get started, and then how to assess along the way to see if and when an RN was needed, and how to pay for it. Two, Clarify recommended a small change to how they do their  appointment template, specifically how they block time for same-day appointments. This process improvement enabled office administrators to easily quantify same-day appointments, something that’s common sense and important in understanding their access needs - which also happens to be a PCMH Recognition factor.

Clarify met on-site several times during the course of this project, but the vast majority of the work and communication was electronic or by telephone, with absolutely no issue.

Data and Analytics and Population Health...oh my!

This practice wanted and needed the ability to compare performance by location and by provider. Clarify worked with the practice on reports they have access to from the EHR and how to use them. We also worked with them on reports and processes they track on spreadsheets that are used to track certain types of referrals and labs. Understanding which reports they have access to and having a tangible reason to run them, forced them (and every other group we’ve worked with) to take a closer look at their data. Running reports, understanding what the data means, and how you can use it allowed for greater insight into certain activities and care metrics to show areas where they were doing well and also ones where there was some variation by site or provider. After you see and understand what your data is telling you, it’s easier to make good decisions, and prioritize. A few small first steps and insights encouraged this incredible group to put more effort and attention on data, and track population health and outcomes. This practice is now better able to monitor its chronic care patient populations, while also helping them lay the foundation for more population health management activities, and they have the right attitude and dedication to continue getting better all the time.

Project Outcomes

There’s no I in TEAM

This pediatric group was equipped with a determined staff that was ready to tackle the Recognition process. PCMH Recognition has allowed this group to negotiate higher fee schedules, as well as prepare them for the transition to value based reimbursement. They’ve also been approached by health systems, clinically integrated networks and ACOs in the region to partner, and this would give them access to a much higher fee schedule than they could negotiate on their own. Their work and dedication to their practice and patients makes them a more desirable and sought after partner in delivering care, lowering overall healthcare costs and improving outcomes. 

This pediatric group has an excellent internal team, but they didn’t have the internal resources or expertise on PCMH Recognition or population health, so they partnered with Clarify to help them get to the finish line more quickly, to make better decisions and to benefit from our years of experience. It just makes sense. We really care for and want the best for our clients, and we do everything we can to ensure they are successful. Clarify helped them save valuable time and steps, prevented them from making unnecessary expenditures and even made some simple cost savings recommendations. Time is valuable to every healthcare organization, and Clarify was able to help them achieve PCMH Recognition more quickly while also allowing staff at the practices to continue their duties without stress or distraction. Reports and working with their EHR was another area of focus, and with direction from Clarify combined with their team’s deep organizational understanding, the practice has been enabled to make data driven decisions, manage given populations, and negotiate better fee schedules, resulting in higher reimbursements. 



- 20 locations
- 75-100 providers
- Physician-owned, independent


- Achieve PCMH Recognition
- EHR optimization
- Case management implementation
- Process and technology improvement


- All primary care locations received PCMH Recognition
- $1.7 million increase in revenue
- Better chronic care patient management
- Ability to negotiate more risk based contracts


Success in Innovation

Clarify has been pioneering practice innovation since 2009. One project was an independently owned primary care group with over 20 locations and close to 100 providers.The practice was forward thinking and open to trying advanced models that would benefit both their patients, providers, care team members and the practice. As a result of their efforts on population health management, patient-centered medical home (PCMH), and EHR optimization (among other things), they renegotiated all of their contracts. They saw opportunities to increase revenue by taking a more proactive and data-driven approach to healthcare, and they capitalized. 

Our work with this group included PCMH Recognition, EHR produced reports and documentation tweaks, implementing case management, and improving technology and processes. This project began at a time when there was very little literature, evidence and few experts in the areas of PCMH. The practice boldly took on the PCMH Recognition process, and achieved NCQA PCMH Level III Recognition at all their locations, and improved process and outcome measures.


PCMH Recognition Process & Practice Optimization

Someone has to be first

Success for this project required we develop and repeatedly implement a rapid cycle improvement plan to optimize practice performance. There was very little literature on the subject and proof of financial benefits were difficult to obtain, making it hard to determine in advance which changes and improvements would work. Presented with these difficulties Clarify began their own research and development (R&D). They researched ideas, reached out to leaders in other states, collaborated with internal leaders and providers, introduced small changes and improved iteratively. We ran pilot tests at one office, received feedback and analyzed reports from the office, and then made a decision on whether or not (and how) the idea should be implemented throughout the practice.

How can we do more to help patients?

The practice wanted to create patient education programs and increase the volume and quality of patient resources. Each site had an assigned case manager. The case managers served to educate patients, offer them resources and connect them with practice and community resources, as needed. The education focused on education, prevention, all with the goal to increase a patient’s ability to self-manage. This means a patient’s ability to care for themselves, and their feeling of confidence in their ability to manage their disease(s), lifestyle change(s) and medication(s). Classes began for disease education, tobacco cessation and nutrition classes. Case managers also served to help find and connect patients to financial resources, and serving as patient advocates. We also helped the practice build key partnerships to help add resources, awareness and make the programs more robust. 

The work this practice did changed lives, and it also showed up in their data. The practice saw improved body mass index (BMIs), fewer emergency room visits, and an overall healthier patient population.


Data Documentation and Analysis

The practice made changes to the EHR system to allow providers and care teams to document more consistently and benefit from evidence-based medication at the point of care. It also allowed for documentation of more items in a structured format to allow for better reporting capabilities. The practice was able to generate more detailed and timely reports, and to learn how to use them. The reports helped providers make data-driven decisions about the treatment of their patients, and allowed them to do more impactful population health management activities. Modifying the EHR, reports, and speaking to providers and care teams about their performance data, encouraged the practice to become more reliant on data and it made a big difference. 

Project Challenges & Outcomes

measured in success

This large, multi-location practice received NCQA PCMH Level III Recognition for all their practices, built a case management department and offered regularly held patient education classes within 12 months, despite the inherent challenges of a project of this size and complexity. 

In one year, the practice generated an additional $1.7 million in revenue because of their PCMH programs and contracts. Being PCMH Recognized also saved the partner health plan $3 million in spending in one year for a group of 1500 patients. Emergency room visits were reduced by 32% and inpatient days were reduced by 36%. Providers in the practice were better able to manage their patients with chronic diseases, which gave them the opportunity to negotiate more risk-based contracts, and resulted in higher fee schedules. This was made possible through the PCMH programs, population health, reports, and their willingness to be bold and to be a leader amongst their peers. 


Going into this project, the practice had few resources available to assist with the PCMH, population health, case management, and disease education projects, but they used their ability to adapt, research, and think critically to succeed. They believed in themselves and refused to fail. They were able to not only achieve their goals but they championed the PCMH Recognition process and were able to gain proof of the benefits that come from making data-driven decisions. As a direct result of their hard work, this group better understood their patient populations, providers, and believed in the consistently high quality care provided enough to take on more risk and challenges than their competitors, and it certainly paid off for the group in many ways.