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Patient Centered Medical Home

 

The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care.

 

The PCMH represents a comprehensive health care model that facilitates partnerships between individual patients, their provider teams, and the patient's family.

 

PCMH is patient care delivery that is holistic and coordinated.

 

Key Elements Include:

Patient-centered care                                            Team approach to care

Use of advanced information systems                   Whole person orientation

Care provided in a community context                  Redesigned primary care offices

Personal medical home designation                      Elimination of access barriers

Focus on quality and safety

 

The transformation to a PCMH is estimated to take 3 to 5 years.

For “Highlights of the path to PCMH,” click here.

 

Blue Cross Blue Shield PGIP-PCMH

PGIP Resources

             Clinical Information Technology-focused Initiatives

             Condition-focused Initiatives

             Core Clinical Process-focused Initiatives

             Service-focused Initiatives

             Organized Systems of Care Initiatives

 

PCMH Resources

             PCMH PowerPoint Presentation

             PCMH PowerPoint Presentation Read Along

2011-2012 Capabilities Summary (2 pages)

2011-2012 Interpretive Guidelines to PCMH Domains of Function 

Principles of a Patient Centered Medical Home

JPA Training Webinars

Michigan Primary Care Transformation Project (MiPCT)

1.0 - Patient Provider Partnership (PPA)

· 2012 Fact Sheet

· 2012 Initiative Plan

· Guidelines for Distribution of the PPA

· PPA Policy - Contact JPA

· PPA Template (One page document)

· PPA Brochure Template

· PCMH flyer

 

2.0 - Patient Registry

· 2012 Fact Sheet

· 2012 Initiative Plan

· Cielo Registry

· Evidenced Based Guidelines - Michigan Quality Improvement Consortium (MQIC)

· PCMH Disease Registries

· Phytel

 

3.0 - Performance Reporting

· 2012 Fact Sheet

· 2012 Initiative Plan

 

4.0 - Individual Care Management

· 2012 Fact Sheet

· 2012 Initiative Plan

· Chronic Care Model

· Group Visits

· PCMH Planned Care

· Planned Visits

· Team Care

· TransforMed

· 4.8/4.14 - Planned Visit Workflow Template

 

5.0 - Extended Access

· 2012 Fact Sheet

· 2012 Initiative Plan

· Interpreter Listings for Jackson, MI

· Extended Care Access Policy - Contact JPA

· Advanced Access Policy 30% - Contact JPA

· Advanced Access Policy 50% - Contact JPA

 

6.0 - Test Results Tracking & Follow-Up

· 2012 Fact Sheet

· 2012 Initiative Plan

 

8.0 - E-Prescribing

· 2012 Fact Sheet

· 2012 Initiative Plan

· Clinicians Guide

        Vendors

· Allscripts

· DrFirst

· National ePrescribing

· RxNT

· SureScripts

9.0 - Preventative Services

· 2012 Fact Sheet

· 2012 Initiative Plan

· 9.5 - Adult Smoking Education

· 9.6 - Standing Order Examples:

* Influenza Adult/Child

* Tylenol/Ibuprofen

* Delsym/Robitussin

* Zertec/Claritin

* Little Noses Saline Drops/RID/Miralax

* Lidocaine/Epinephrine/Glycerin Suppository

· 9.9 - Preventative Planned Visit Template

 

10.0 - Linkage to Community Services

· 2012 Fact Sheet

· 2012 Initiative Plan

· Central Michigan 2-1-1

· JPA’s Community Resource Database for Jackson County

· Printable Community Resource List

· 211 Brochure

· 211 Informational Materials

 

11.0 -  Self-Management Support

· 2012 Fact Sheet

· 2012 Initiative Plan

· Self-Management Overview

· Self Management Support Toolkit

· Engaging the Patient

· SMART Goal Plan

· Self-Management Survey

· STAFF TRAINING VIDEOS (Clinical)

 

12.0 - Patient Web Portal

· 2012 Fact Sheet

· 2012 Initiative Plan

 

13.0 - Coordination of Care

· 2012 Fact Sheet

· 2012 Initiative Plan

· Payer Case Manager Contact List

· Medical Release Form

· Care Transitions - Letter to Patient Template

· Care Transitions - Plan Template

· Care Transitions - Staff Training

· Coordination of Care Policy (EMR)- Contact JPA

· Coordination of Care Policy (No EMR)-Contact JPA

 

14.0 - Specialist Referral Process

· 2012 Fact Sheet

· 2012 Initiative Plan

· Specialist Referral Contact List

· Specialist Referral Policy (EMR) - Contact JPA

· Specialist Referral Policy (No EMR)