California Academy of Family Physicians Fresno PCMH Initiative

Program Location: 
Fresno, CA
Payer Type: 
Partner Organizations: 
California Academy of Family Physicians
Fresno Unified School District (FUSD)
Community Medical Providers (CMP)

Reported Outcomes


Launched in July 2012, the Fresno PCMH Pilot project was a collaboration of California Academy of Family Physicians (CAFP), the self-insured Fresno Unified School District (FUSD) and a primary care physician group, Community Medical Providers. The pilot included 2,500 patients (10 percent of FUSD’s beneficiaries).

Eight Community Medical Providers (CMP) practices received initial PCMH coaching from HealthTeamWorks. By December 2012, the CMP quality improvement (QI) coach had expanded the PCMH project to all 16 CMP practice sites. Physicians, other providers and staff learned about the PCMH model and change management; transitioning to team-based care; using registries to better track patient conditions and the care received; using more-sophisticated data collection from electronic health records (EHR) to evaluate care and outcomes; hiring a QI coach to coordinate ongoing change work, measurement and feedback; and hiring a complex case manager to proactively reach out to high- risk patients.

Payment Model: 

The pilot implemented a three-tiered blended payment model that included the usual fee-for-service payments for visits and services; a care coordination and health information technology upgrade fee; and bonus payments for achieving quality improvements and cost reductions.

Fewer ED / Hospital Visits: 
  • Medication adherence among high-risk members increased, while high-risk member costs decreased and overall inpatient admissions and emergency department visits also decreased 
  • Inpatient admissions decreased by nearly 22%
  • Emergency department visits decreased by more than 3%
Improved Health: 
  • At the end of the year-long pilot the number of patients with diabetes for whom blood sugar had been confirmed as under control increased by 50%
Improved Patient/Clinician Satisfaction: 
  • overall improvement in patient satisfaction (no statistic cited)
Cost Savings: 
  • The cost of total claims decreased by 9% for a gross savings of $972,519
  • High-risk member costs decreased by16%
Increased Preventive Services: 
  • Breast cancer screening and body mass index counseling increased across the entire patient population and patient satisfaction improved
Last updated February 2015
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