1. Establishing a Primary Care Medical Home
Dr. Michael Romano and Oscar Perez TTUHSC
DSRIP RHP 15
April 19th, 2013

2. 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

3. Agency for Healthcare Research & Quality
Comprehensive
Patient-Centered
Coordinated
Accessible
Quality and Safety

4. 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

5. 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

6. 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