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Patient Centered Medical Home and Team-Based Care

(Updated January 12th 2017)

Patient-Centered Medical Home

The Patient-Centered medical home (PCMH) is described as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, compassion, and enable strong and trusting relationships with providers and staff.

Team-Based Care

Patient-Centered Medical Home (PCMH) capabilities involve a team-based approach to patient care. Care teams are groups of primary care staff members working with the PCP to collectively take responsibility for a set of patients. Care teams blend multidisciplinary skills, focusing several people's insights on each patient's individualized plan of care. High-functioning teams deliver care in such a way that all team members work to the top of their ability and license and play a role in delivering preventive services and managing chronic diseases. The Care Manager works in close partnership with the PCP and all team members to provide coordinated, non-duplicative patient care.

 

 

Webinars and Presentations

MiCMRC/MiPCT Educational Webinar

Feb 24 2016

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Alpine Internal Medicine and Pediatrics, Cereal City Pediatrics, Moazami Pediatrics, New Day Family Medicine, and CHC Fort Gratiot

MiPCT Webinar

Aug 21 2013

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Kerrie Barney, RN, BSN, CHPN Hybrid Care Manager, Lakeshore Family Care

MiPCT Pediatric Webinar

May 15 2015

To receive a certificate of completion Click Here

Webinar replay video

Presented by

Jane Pilditch & Kristen Hawkins, MI Family to Family Health Information Center

Tools

Tools

Patient-Centered Interactions

From the Safety Net Medical Home Initiative. Includes implementation guide, tools and other resources

Tools

Care Coordination Toolkit

From the California Healthcare Foundation via Improving Chronic Care

Articles

Article

Team-Based Care Articles

Article

Patient Centered Medical Home Articles

Article

Patient-Centered Care: What Does It Take?

From the Commonwealth Fund. Executive summary describes patient-centered care and success models. October 2007

Resources

Guides and Policies

What Does Embedment Look Like?

Takes a look at how care management is integrated within the practice.

Guides and Policies

Quality Improvement Strategy

From the Safety Net Medical Home Initiative

Implementation-Guide-QI-Strategy-1.pdf

QI Strategy Implementation Guide Part I: Choosing and Using a QI Framework

Part 1 of the QI Strategy Implementation Guide Series includes an overview of QI methods and provides detailed information and case studies. August 2011

Implementation-Guide-QI-Strategy-2.pdf

QI Strategy Implementation Guide Part 2: Optimizing Health Information Technology for Patient-Centered Medical Homes

This guide describes how clinics can optimize health information technology to power medical home workflows. It also includes tips for clinics without electronic health records. March 2011

Website

Website

BCBSM Physician Group Incentive Program

The PGIP program supports and facilitates practice transformation using a variety of incentives

Website

AAFP Patient-Centered Medical Home Criteria

From the American Academy of Family Physicians

Website

AHRQ Patient-Centered Medical Home Resources

From the Agency for Healthcare Research and Quality

Website

NCQA Patient-Centered Medical Home Resources

From the National Committee for Quality Assurance

Website

Medical Home Portal

Website with information about many pediatric chronic health conditions and tips about how to build a family centered medical home. It is an excellent resource for professionals and family members

Website

Improving Chronic Illness Care

Website focused on chronic care model and includes tools, literature, resources