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Patient Centered Medical Home

Patient Centered Medical Home. What it means for Duffy Health Center Board Presentation September 10 th 2012. Patient Centered Medical Home. The aim is increased access to quality patient care It involves a team based approach to care. DEFINITION OF PCMH LEVEL 1. 6 MUST-PASS ELEMENTS 1A

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Patient Centered Medical Home

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  1. Patient Centered Medical Home What it means for Duffy Health Center Board Presentation September 10th 2012

  2. Patient Centered Medical Home • The aim is increased access to quality patient care • It involves a team based approach to care

  3. DEFINITION OF PCMH LEVEL 1 • 6 MUST-PASS ELEMENTS • 1A • Providing Same Day Appointments • Providing timely clinical advice by telephone • Documenting clinical advice in the medical record

  4. PCMH 2D Use Data for Population Management • Practice uses patient information, clinical data and evidence based guidelines to generate lists and proactively remind patients and clinicians about • At least 3 different preventive care services • At least 3 different chronic care services • Patients not recently seen by practice • Specific medications.

  5. PCMH 3C – Care Management - Patient collaboration with individual care plan including treatment goals • Written plan of care/Clinical summary • Assess and Address barriers when treatment goals not met • Identify patients/families who might benefit from additional care management • Follow up if missed appointments

  6. PCMH 4A – Support Self Care Process - Provides educational resources to at least 50% patients in the identified group to assist in self management - Develops and documents self management plans - Provides self management tools - Documents self management abilities - Counsels on adopting healthy behaviors

  7. PCMH 5B – Referral Tracking and Follow up - Tracking referral status including timing - Following up to obtain specialist’s report - Providing electronic summary of care record for >50% referrals - Asking patients about self-referrals and requesting reports -Demonstrate capability of electronic exchange of key clinical information

  8. PCMH 6C- Implement Continuous Quality Improvement - Set goals and act to improve performance on 3 clinical quality and resource measures - Set goals and act to improve performance on at least 1 patient experience measure -Set goals to address 1 identified disparity in care or service for vulnerable populations


  10. New Tasks that will be added as part of PCMH • Disease registry data entry, maintenance, monitoring • Increased patient outreach, phone contact • Increased results reporting • Time intensive patient education • Group visits • Motivational interviewing

  11. New Tasks cont’d • Self management follow up • Expanded hours • Open access • Increased patient phone, email access • More thorough documentation • Increased patient follow up • Increased communication with other providers/specialists

  12. New Tasks mean cross training staff and elevating to top of license care • Examples • Providers – develop medical care plan which lower level staff can carry out and monitor • RN uses care plan to assess and treat complex patients, also educate and coach chronic patients e.g. strep throat protocol, STD training protocol • MA – maintain disease registry, basic admin tasks • Front desk – keep data for open access scheduling, follow up patients who don’t keep specialists appointments

  13. Suggestions for achieving New Tasks • INFRASTRUCTURE • TIME • STAFF – RN CARE MANAGER

  14. PROPOSED TIMELINE • September 13th – Follow up start of open access – Medical/BH • September 27th – BH open access, follow up data from Medical, decide clinical reminders • October 11th – Team formation, challenges with BH, decide with PIC input on which groups high risk

  15. PROPOSED TIMELINE CONT’D • November 5th – Patient experience is one of the measures, review current survey and/or use developed survey • December – data review, places where we need improvement

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