Patient Centered Medical Home and Team-Based Care | Michigan Care Management Resource Center

(Updated December 18th 2018)

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.

Practice Facilitation Handbook Module 19. Implementing Care Teams

From the Agency for Healthcare Research and Quality

Defining the Medical Home

From the Patient-Centered Primary Care Collaborative

Tools

The Primary Care Team Guide

The Primary Care Team Guide provides step by step direction on how to establish these high-functioning teams and implement new functions essential to team-based care. Numerous tools and resources from 31 practices nationwide are made avaialble to support you.

Primary Care Team Guide

Tools

Team Based Care

Team Huddle Checklist

A checklist from the American Medical Association Steps Forward

4.4 Team huddle Checklist.pdf

Huddle Checklist

Tools

Patient-Centered Interactions

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

Safety Net Medical Home Initiative - Patient-Centered Interactions

Tools

Care Coordination Toolkit

From the California Healthcare Foundation via Improving Chronic Care

care_coordination_toolkit.pdf

Reducing Care Fragmentation - A Toolkit for Coordinating Care

Tools

Team Huddle Tool

Copy of Huddle Process tool.pdf

Huddle Process Tool

Videos

Role of the Clinical Pharmacist

Provides information on the role of a clinical pharmacist on the care management team.

Click Here for Video

Articles

Article

Team Based Care

Team-Based Primary Care: Convergence of Improving Engagement, Safety, and Enhanced Joy in Practice

The physician leadership in the primary care practices of Bellin Health in Green Bay, Wisconsin, knew that they needed to make some changes in how they delivered care . . .

BEllin teambased-1.pdf

Team Based Care - Bellin Health

Article

Team-Based Care Articles

Implementation-Guide-Engaged-Leadership.pdf

Implementation Guide: Engaged Leadership - Strategies for Guiding PCMH Transformation

From the Safety Net Medical Home Initiative

Team Building in Primary Health Care

From the Enhancing Interdisciplinary Collaboration in Primary Health Care (EICP) Initiative. A guide is to assist teams to better understand processes and find ways to strengthen team-based care in the physician office setting

Keys to High-Functioning Office Teams

From the Family Practice Management journal of the American Academy of Family Physicians. May/June 2011

Huddles: Improve Office Efficiency in Mere Minutes

From the Family Practice Management journal of the American Academy of Family Physicians. June 2014

Article

Patient Centered Medical Home Articles

The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers

From PubMed. Reid RJ, Coleman K, Johnson E, Fishman P, Hsu C, Soman MP, Trescott CT, Erikson M, Larson EB. Health Affairs. May 2010

Value and the Medical Home: Effects of Transformed Primary Care

From PubMed. Geisinger Health System PCMH Implementation. Gilfillan RJ, Tomcavage J, Rosenthal MB et al. American Journal of Managed Care. August 2010

Driving Quality Gains and Cost Savings through Adoption of Medical Homes

From Health Affairs. Fields, D, Leshen, E. Patel, K. Health Affairs. May 2010

Resources

Guides and Policies

A List of Foundational Courses and Resources for Physician Office Team Members

A list of Foundational courses and resources which may be useful for Physician Organizations to consider for Physician Office team members who seek additional training.

Resource list additional training for PO-Practice Team Members v4.pdf

Guides and Policies

Team-Based Care

What Does Embedment Look Like?

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

What does care managment embedment look like.docx

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

Safety Net Medical Home Initiative Quality Improvement Strategy

Additional QI resources from the Safety Net Medical Home Initiative

Website

Community Resources

Michigan Community Health Worker Alliance

MiCHWA is a group of community health workers (CHWs), organizational partners, and other CHW supporters. MiCHWA's mission is to promote and sustain the integration of community health workers into health and human services organizations through coordinated changes throughout Michigan in policy and workforce development. MiCHWA's governance structure includes a Board of Directors, a CHW Network Advisory Board, a Finance Committee as well as four working groups.

Michigan Community Health Worker Alliance

Website

BCBSM Physician Group Incentive Program

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

About the Physician Group Incentive Program

PGIP Models of Care

Includes PGIP Patient Centered Medical Home Initiatives

Website

AAFP Patient-Centered Medical Home Criteria

From the American Academy of Family Physicians

The Patient-Centered Medical Home (PCMH)

Website

AHRQ Patient-Centered Medical Home Resources

From the Agency for Healthcare Research and Quality

The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care

Peikes D, Genevro J, Scholle SH, Torda P. AHRQ Publication No. 11-0029. Rockville, MD: Healthcare Research and Quality. February 2011

Website

NCQA Patient-Centered Medical Home Resources

From the National Committee for Quality Assurance

Patient-Centered Medical Home Recognition

Website

Patient Centered Medical Home

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

Medical Home Portal

Website