PCMH TransformationPCMH变换.pptVIP

PCMH TransformationThomas McCarrick, MDTown Medical Associates Where we were, and where we need to go… Our Practice Suburban New Jersey 7 Family Practice Physicians and 4 Physician Assistants Established practice – over 25 years EHR for 4 years Extended office hours 6 days/wk Inpatient care by hospitalists * The Realization As we worked our way through the tedious reporting requirements of the NCQA PCMH recognition process it became apparent that the primary underlying theme is that we need to become more active managers of our patients healthcare needs. Almost everything else we did was a downstream tool or implementation. * Our Map Where we were: Primary care focused Good availability Good relationships with patients and community Episode based management No significant data driving clinical care Where we’re going: Primary care focused Expanded availability Good relationships with patients and community Population based management Data driven Improved communications Expanded disease management Improved discharge and transition handoffs Better ways to manage our patients with access issues * The Starting Point Horizon’s decision to use diabetes as a fulcrum for PCMH development helped up focus on a smaller number of patients, reports, processes and tools that could later be expanded. * What We Did Retooled our computer system processes to create alerts for incomplete diabetes and preventive care services Hired a part time certified diabetes educator to teach Diabetes Self Management classes as well as individual counselling. In the process our office became a Diabetes Education Center. Recognizing that insulin therapy is a weak spot in primary care, we got our staff and physicians additional training in patient education for insulin administration. Ran an in-house diabetes education program for our providers, led by a diabetologist and focused on insulin therapy and using case studies of our most poorly controlled diabetic patients. Revamped our web s