Establishing a Primary Care Medical Home for Improved Patient Care
"Learn about the development of a Primary Care Medical Home at Kenworthy Family Medicine Clinic focusing on patients with diabetes, emphasizing patient-centered care, NCQA accreditation, and advanced care management. Explore the next steps in disease management and e-referral processes." (299 characters)
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Establishing a Primary Care Medical Home Dr. Michael Romano and Oscar Perez TTUHSC DSRIP RHP 15 April 19th, 2013
Development of a Primary Care Medical Home Re-Design of the Kenworthy Family Medicine Clinic as a NCQA Patient Centered Medical Home Focuses on patients with Diabetes High prevalence in our region Particular burden in Hispanics Amenable to intervention Links to 2 other DSRIP projects Ocular Care Chronic Disease Management Registry
Agency for Healthcare Research & Quality Comprehensive Patient-Centered Coordinated Accessible Quality and Safety
NCQA Accreditation Access and communication Patient tracking and registry functions Care management Self-Management support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Electronic Communications
Kenworthy Family Medicine Initiative Well- established Open- access Scheduling 30% Same-day Appointments Organized Patient Population into 3 Teams 3 to 4 Faculty 8 Residents 1 LVN 4 MA s Staff support for prior authorizations and results management Pharmacy and Dietary Support Advanced practice providers as part of team
Kenworthy Family Medicine Initiative Next Steps Disease Management Registry Software Begin with Diabetes Patient Portal Family Medicine will be first PLFSOM site in go-live. Est. September 2013 Development of e-referral process From FM to Ophthalmology Facilitate and Track Referrals
