Patient-Centered Medical Home or PCMH is a system of care based on the relationship between a patient and their Primary Care Physician (Pediatrician, Internist, and Family Practice Doctor). The Primary Care Physician or PCP leads a proactive healthcare team to provide long-term coordination and management of their patients’ healthcare across all settings. As part of the Patient-Centered Medical Home concept patients take an active role in their own healthcare, working closely with their Primary Care Physician.
The goal of the Patient-Provider Partnership initiative is to expand physician and patient awareness of the Patient-Centered Medical Home model, and strengthen the bond between patients and care-giving team.
The goal of the Patient Registry initiative is to establish a registry that contains comprehensive patient clinical and demographic information that can be used to effectively manage a population of patients.
The goal of the Performance Reporting initiative is to implement reporting technology that will allow providers to evaluate how effectively they are delivering services and treatment to their chronic care population.
The measurement tools will generate data detailing patterns of care, and provide actionable data that will help providers to set goals, implement solutions, and improve performance.
The goal of the Individual Care Management initiative is to ensure that patients with chronic conditions receive organized and well planned care that will help them to take greater responsibility for their health.
The goal of the Extended Access initiative is to ensure that all patients have comprehensive and timely access to providers and are able to receive health care services in the least intensive, most appropriate setting based on their individual needs.
Patients who have access to clinical decision makers are better equipped to make time sensitive health care choices and ultimately choose the most appropriate level of care.
The goal of the Test Tracking ineitiative is to implement a standardized, reliable test tracking system to ensure that patients receive needed tests, results are communicated in a timely manner, follow-up appropriate to the patient care is conducted, and each step in the test tracking process is properly documented.
The goal of the Preventive Services initiative is to coordinate patient care through Primary Care Physicians in a Patient Centered Medical Home. Screening, active counseling, and outreach efforts will be used to inform and educate patients about preventive care.
The goal of the Linkage to Community Services initiative is to help patients connect with community resources by implementing processes that coordinate care between the health system, community service agencies, family caregivers, and the patient.
The goal of the Self-Management Support initiative is to offer support to patients as they learn to assume responsibility for daily management of their chronic conditions.
The goal of the Patient Web Portal initiatives is to support optimal management of patients with chronic conditions by using a patient web portal to allow for electronic communication between patients and physicians, and provide greater access to medical information and technical tools.
The goal of the Coordination of Care initiative is for patient care to be coordinated across health systems through a process of active collaboration and communication between providers, caregivers, and the patient.
The goal of the Specialist Referral Process initiative is to create a well-coordinated process where patients from primary care are referred to specialty care in an efficient manner; and both providers receive timely access to the information they need to provide optimal care to the patient.
